Oral and Maxillofacial Surgery for the Clinician

Description

This is an open access book with CC BY 4.0 license. This comprehensive open access textbook provides a comprehensive coverage of principles and practice of oral and maxillofacial surgery. With a range of topics starting from routine dentoalveolar surgery to advanced and complex surgical procedures, this volume is a meaningful combination of text and illustrations including clinical photos, radiographs, and videos. It provides guidance on evidence-based practices in context to existing protocols, guidelines and recommendations to help readers deal with most clinical scenarios in their daily surgical work. This multidisciplinary textbook is meant for postgraduate trainees, young practicing oral surgeons and experienced clinicians, as well as those preparing for university and board certification exams. It also aids in decision-making, the implementation of treatment plans and the management of complications that may arise. This book is an initiative of Association of Oral and Maxillofacial Surgeons of India (AOMSI) to its commitment to academic medicine. As part of this commitment, this textbook is in open access to help ensure widest possible dissemination to readers across the world. Preface Contents List of Videos Chapter Contributors and Video Contributors Contributors Video Contributors About the Editors Part I: Introduction 1: Oral and Maxillofacial Surgery in India: How Did We Get Here and Where Are We Going? 1.1 History of Our Missions and Our Challenges 1.2 Expertise, Familiarity, and Competence 1.3 Predicting the Future References Part II: Preoperative Assessment and Patient Preparation/Optimization 2: Preoperative Evaluation and Investigations for Maxillofacial Surgery 2.1 Introduction 2.2 Preoperative Evaluation 2.3 Laboratory Investigations 2.4 Preanesthetic Evaluation 2.5 Aspects of Evaluation Unique to Anesthesia 2.6 Assessment of the Pediatric Patient 2.7 Assessment of the Elderly Patient 2.8 Specialist Consultation and Work-up 2.9 The Process of Risk Assessment 2.10 Risk Reduction Strategies 2.10.1 Premedication [4] 2.10.2 Fasting Guidelines 2.10.3 Perioperative Beta-Blocker Therapy 2.10.4 PONV Prophylaxis [47] 2.10.5 Plan for Postoperative Analgesia [51] 2.11 Preoperative Decision Making and Obtaining Informed Consent: The Team Concept [53] 2.12 Conclusion References 3: Management of Medical Comorbidities in Maxillofacial Surgery 3.1 Introduction 3.2 Changing Demographics in India 3.3 Lifestyle Changes in India 3.4 The Changing Face of Oral and Maxillofacial Surgery 3.4.1 Medical History and India 3.5 Cardiovascular System 3.5.1 Hypertension 3.5.1.1 Minor Oral Surgery 3.5.1.2 Major Maxillofacial Surgery 3.5.1.3 Vasoconstrictors and Hypertension 3.5.2 Ischemic Heart Disease (IHD) 3.5.2.1 Minor Oral Surgery 3.5.2.2 Major Surgery 3.5.3 Postintervention Cardiac Patients 3.5.3.1 Percutaneous Coronary Angioplasty (PTCA) and Coronary Artery Bypass Graft (CABG) and Valve Replacement Procedures 3.5.4 Conventional Antiplatelets, Anticoagulants, and Novel Oral Anticoagulants (NOAC) 3.5.4.1 Minor Dentoalveolar Surgery: Antiplatelets 3.5.4.2 Maxillofacial Surgery 3.5.4.3 Bridging with Heparin 3.5.4.4 Anticoagulants and Oral/Maxillofacial Surgery 3.5.4.5 Minor Oral Surgery 3.5.4.6 Major Maxillofacial Surgery 3.5.5 Infective Endocarditis Prophylaxis 3.5.6 Implantable Cardioverter Defibrillators (ICD) 3.5.6.1 Implications 3.6 Impact of Central Nervous System Disorders in Maxillofacial Surgery 3.6.1 Epilepsy 3.6.1.1 Basic considerations 3.6.1.2 Outpatient maxillofacial considerations 3.6.1.3 Major Surgical Considerations 3.6.1.4 Precautions, complications, & management 3.6.1.5 Management of an acute episode on the dental chair 3.6.2 Stroke 3.6.2.1 Basic Considerations 3.6.2.2 Maxillofacial considerations 3.6.2.3 Precautions 3.7 Impact of Psychiatric Disorders in Maxillofacial Surgery 3.7.1 Maxillofacial Considerations 3.8 Dental and Maxillofacial Implications in Liver Disease 3.8.1 Introduction 3.8.1.1 The Function of the Liver [36] 3.8.2 Classification of Liver Dysfunctions [35] 3.8.2.1 Viral Hepatitis 3.8.2.2 Autoimmune Hepatitis 3.8.2.3 Fulminant Hepatitis 3.8.2.4 Cirrhosis 3.8.2.5 Hepatocellular Carcinoma 3.8.2.6 Alcoholic Liver Disease 3.8.3 Oral Manifestations of Liver Disease 3.8.4 Implications of Liver Disease 3.8.4.1 Liver Disease and Maxillofacial Surgery 3.9 Maxillofacial Implications in GI Disorders 3.9.1 Perioperative Maxillofacial Implications 3.9.1.1 GERD 3.9.1.2 Peptic Ulcers 3.9.1.3 Ulcerative Colitis 3.10 Pregnancy 3.10.1 Physiologic Changes 3.10.2 Treatment Protocol 3.10.2.1 Minor Surgery 3.10.2.2 Dental Radiology 3.10.2.3 Major Surgery 3.10.3 Drug Usage in Pregnancy 3.11 Endocrine Disorders 3.11.1 Diabetes 3.11.1.1 Management of Patients Undergoing Procedures 3.11.1.2 Preoperative Glycemic Control in patients on Oral Hypoglycemic Agents 3.11.1.2.1 Minor surgery 3.11.1.2.2 Major surgery 3.11.1.3 Preoperative Glycemic Control in Type 2 Diabetics on Insulin 3.11.1.4 Preoperative Glycemic Control in Type 1 Diabetics on Insulin 3.11.1.4.1 Minor surgery: 3.11.1.4.2 Major surgery: 3.11.1.4.3 Intraoperative glycemic control: 3.11.1.4.4 Postoperative glycemic control: 3.11.2 Hypo/Hyperthyroidism 3.11.2.1 Hypothyroidism 3.11.2.1.1 Physiologic Challenges 3.11.2.1.2 Management 3.11.2.2 Hyperthyroidism 3.11.3 Adrenal Gland Disorders 3.11.3.1 Primary Adrenocortical Hypofunction 3.11.3.2 Secondary Adrenocortical Insufficiency 3.11.4 Renal Disorders 3.11.4.1 Acute Renal Failure (ARF) 3.11.4.2 Chronic Renal Failure (CRF) 3.12 Patients with Non-head and Neck Malignancies 3.12.1 Introduction 3.12.2 Treatment Protocol 3.12.2.1 Chemotherapy 3.12.2.2 Radiotherapy 3.12.3 Prevention and Treatment of Osteonecrosis After Chemotherapy and Radiation References 4: Medical Emergencies in Oral and Maxillofacial Surgical Practice 4.1 Introduction 4.2 Acute Asthmatic Attack 4.2.1 Life-Threatening Acute Asthma 4.3 Acute Adrenal Insufficiency/Adrenal Crisis/Steroid Crisis/Addisonian Crisis 4.4 Airway Obstruction 4.5 Anaphylaxis 4.6 Chest Pain 4.6.1 Angina 4.6.2 Myocardial Infarction (Heart Attack) 4.7 Cardiac Arrest 4.8 Hypoglycemia 4.9 Grand Mal Seizures 4.10 Syncope 4.11 Other Causes of Loss of Consciousness 4.12 Conclusion References Part III: Anesthesia for Oral and Maxillofacial Surgery 5: Local Anesthesia in Oral and Maxillofacial Surgery 5.1 Introduction 5.1.1 Historical Background 5.1.2 Definition 5.1.3 Ideal Characteristic of Local Anesthesia 5.2 Classification (Tables 5.1 and 5.2) 5.3 Local Anesthetic Agents 5.3.1 Lidocaine (Lignocaine) 5.3.2 Bupivacaine 5.3.3 Articaine 5.4 Vasoconstrictors 5.4.1 Dilution of Vasoconstrictor 5.5 Causes of Failure of LA 5.6 LA Toxicity and Antidote for Toxicity 5.6.1 Reversal of Cardiomyotoxicity 5.7 Reversal of Soft-Tissue Anesthesia 5.8 Plain Local Anesthetic (Without Epinephrine) 5.9 Topical Local Anesthetic Agent 5.10 Surface Anesthesia 5.11 Methods of Local Anesthetic Administration 5.11.1 Percentage of Blood Vessel Penetration During IANB 5.11.2 Controversy in the Use of Bilateral IANB and Lingual Nerve Block [17] 5.12 Techniques 5.12.1 Inferior Alveolar Nerve Block (Also Known as Mandibular Nerve Block) [Along with Lingual & Long Buccal Nerve Blocks] 5.12.2 Technique 5.12.3 Areas Anesthetized by This Block 5.12.4 Signs and Symptoms of Anesthesia 5.12.5 Complications (Table 5.6) 5.12.5.1 Failure to Obtain Anesthesia 5.12.5.2 Hematoma Formation 5.12.5.3 Transient Facial Nerve Palsy 5.12.5.4 Trismus 5.12.5.5 Accidental Breakage of the Needle 5.13 Vazirani–Akinosi (VA) Versus Inferior Alveolar Nerve Block 5.13.1 Indications for VA [24] 5.13.2 Akinosi–Vazirani Technique (Closed-Mouth Technique) 5.13.3 Technique 5.14 Mental/Incisive Nerve Block 5.14.1 Technique 5.14.2 Areas Anesthetized 5.14.3 Signs and Symptoms 5.15 Nerve Blocks in the Maxilla 5.15.1 Posterior Superior Alveolar Nerve Block Technique 5.15.1.1 Areas Anesthetized 5.15.1.2 Signs and Symptoms 5.15.2 Infraorbital Nerve Block [Also Anterior and Middle Superior Nerve Blocks] 5.15.2.1 Technique 5.15.2.2 Areas Anesthetized 5.15.2.3 Signs and Symptoms of Anesthesia 5.15.3 Palatal Anesthesia 5.15.3.1 Greater Palatine Nerve Block 5.15.3.2 Nasopalatine Nerve Block 5.16 Regional Blocks in Oral and Maxillofacial Surgery 5.16.1 Maxillary Nerve Block 5.16.2 Mandibular Nerve Block 5.16.3 Greater Auricular Nerve Block 5.16.4 Glossopharyngeal Nerve Block 5.16.5 Sphenopalatine Ganglion Block 5.17 Recent Advances in Local Anesthesia 5.17.1 Vibrotactile Devices 5.17.1.1 Vibraject [38] 5.17.1.2 Dental Vibe [39] 5.17.1.3 Accupal 5.17.2 C-CLAD (Computer-Controlled Local Anesthetic Delivery) 5.17.3 Compu-Flo 5.17.4 STA—single tooth anesthesia 5.17.5 Jet Injection 5.17.6 MED-JET H III 5.17.7 Safety Dental Syringes [43] 5.17.8 Devices for Intraosseous Anesthesia [44] 5.18 Conclusion References 6: Office-Based Anesthesia in Oral and Maxillofacial Surgery-The American Model and Training 6.1 Introduction 6.2 Brief History of Anesthesia in OMS 6.3 The Anesthesia Team 6.4 AAOMS Office Anesthesia Guidelines 6.5 Office Requirements 6.6 Record Keeping 6.7 Office Anesthesia Evaluation Program and Parameters of Care 6.8 AAOMS National Simulation Program 6.9 Dental Anesthesia Assistant National Certification Examination (DAANCE) 6.10 Anesthesia Training during OMS Residency 6.11 Preanesthetic Evaluation of the Patient 6.12 Monitoring 6.12.1 Methods for Monitoring Ventilation 6.13 Airway Armamentarium 6.14 Oxygen and Supplemental Gas Delivery System 6.15 Suction Equipment 6.16 Recovery Room 6.17 Techniques in Anesthesia 6.17.1 Enteral Anesthesia 6.17.2 Parenteral Anesthesia: Intravenous Anesthesia and Inhalational Anesthesia 6.18 Emergency Drugs 6.19 Activism and Leadership in  Office-Based Anesthesia Video Links References Additional Reading 7: Anaesthesia for Maxillo Facial Surgery 7.1 Introduction 7.2 Preoperative Assessment 7.2.1 Patients on anticoagulants 7.2.2 Oncology Patients 7.2.3 Trauma Patients 7.2.4 Paediatric Patients 7.2.5 Toxic Airway/Infections 7.3 Airway Assessment 7.4 General Physical Examination 7.4.1 Investigations 7.4.2 Counselling and Reassurance 7.4.3 Informed Consent 7.4.4 Transport to Operation Theatre (OT) 7.4.5 Handover Documents 7.5 Intraoperative Considerations 7.5.1 Before Induction (Figs. 7.2, 7.3, 7.4, 7.5, 7.6, 7.7, and 7.8) [6] 7.5.2 Induction 7.5.3 Monitoring 7.5.4 Airway management: (Flow Chart 1) 7.5.5 Supraglottic Airway Devices 7.6 Special Considerations 7.6.1 Retromolar and Submental Intubation 7.6.1.1 Retromolar Intubation 7.6.1.2 Submental Orotracheal Intubation: [13] (Fig. 7.12a–f) 7.6.2 Eyes 7.6.3 Positioning 7.6.4 Throat Pack 7.7 Maintenance of Anaesthesia 7.7.1 Deep Vein Thrombosis (DVT) Prophylaxis 7.7.2 Control of Bleeding 7.7.2.1 Hypotensive Drugs: (Appendix II) 7.7.3 Elective Tracheostomy 7.8 Post-Operative 7.8.1 Handover from OT to Recovery Room/ICU 7.9 Post-Operative Complications and Management 7.9.1 Airway Problems 7.9.2 Post-Operative Haematoma 7.9.3 Nausea and vomiting [23] 7.9.4 Analgesia [23–25] 7.10 Case Scenarios 7.10.1 Case 1: Cleft Palate 7.10.2 Case–2: Polytrauma with Facial Injuries Appendix I: Dosage of common Drugs Appendix II: Commonly Used Drugs for Controlled Hypotension Appendix III: Handover Form Used for Inter Hospital Transfer Appendix IV: Inter-Hospital Transfer Guidelines References Additional Reading (Sub Mental Intubation) Part IV: Imaging in Oral and Maxillofacial Surgery 8: Radiology for Maxillofacial Surgeons: The Essentials 8.1 Introduction 8.2 Requesting an Imaging Investigation 8.3 Role of the Maxillofacial Surgeon (MFS) Vs. the Radiologist’s expectation from the MFS 8.4 Role of the Department of Imaging and the Radiologist 8.5 Energy Forms Used in Diagnostic Medical Imaging: Understanding the Basics 8.6 Basic Radiology for the Nonradiologist: What the MFS should know? 8.7 Imaging Investigations 8.7.1 Imaging Investigations Using Ionizing Radiation (Photon Energies) 8.7.1.1 X-Rays 8.7.1.2 Computerized Tomography (CT/Spiral CT) 8.7.1.3 Gamma Rays 8.7.1.4 Nuclear Isotope Studies 8.7.1.5 Positron Emission Tomography (PET) 8.8 Radiation: Hazard Awareness and Principles of Protection 8.9 Imaging Investigations Not Involving Ionizing Radiation 8.9.1 MRI (Magnetic Energy Coupled with Radiofrequency Energy) 8.9.2 Ultrasound 8.9.3 Thermography 8.10 Role of Chest Radiograph in the Practice of Maxillo Facial Surgery 8.10.1 Chest Radiographic Evaluation for Optimum Diagnostic Quality 8.10.2 Reading a Chest Radiograph: Interpretation Basics 8.10.3 Requesting a Chest Radiograph: Clinical indications 8.10.3.1 Preoperative evaluation 8.10.3.2 Intra- / Postoperative recovery room 8.10.4 “The Chest Radiograph. A Mysterious Treasure”…the More you Search, the More you Find!! 8.10.4.1 Consolidation 8.11 Role of High Resolution Ultrasonography (HRUSG) as a Diagnostic Aid in the Practice of Maxillofacial Surgery 8.11.1 Preface 8.11.2 Gross Cheek Anatomy 8.11.3 Floor of Mouth, Anatomy (Relevant to HRUSG) 8.11.4 Defining the HRUSG Anatomy of Maxillofacial Region (Predominantly Cheek) 8.11.5 Techniques of HRUSG of Cheek 8.11.6 Case Presentation 8.12 Conclusion References Further Reading Part V: Principles of Maxillofacial Surgery 9: Operating Room Protocols and Infection Control 9.1 Introduction 9.2 Terminology 9.3 Surgical Site Infections 9.4 Surgical Safety 9.5 Environmental Control and Design 9.6 Disinfection and Sterilization 9.7 Operating Room Decorum 9.8 Classification of Surgical Wounds 9.9 Risk Factors Affecting the Rate of Postoperative Wound Infections 9.9.1 Factors Influencing the Development of Nosocomial Infections 9.9.1.1 The Microbial Agent 9.9.1.2 Susceptibility of the Patient 9.9.1.3 Resistance of the Bacteria 9.9.1.4 Month of Operation 9.9.1.5 Use of Electric Cautery 9.9.1.6 Duration of Operation 9.9.1.7 Spread of Infection 9.10 COVID 19 and Maxillofacial Surgery 9.10.1 Mode of Transmission of SARs-CoV 2 9.10.2 Symptoms 9.10.3 Radiographic Findings 9.10.4 Testing and Laboratory Findings 9.10.5 General Preventive Measures 9.10.6 Personal Protective Equipment 9.10.7 Specific Precautions to Be Taken During Surgery 9.11 Control of Nosocomial Infections 9.11.1 Prevention from Nosocomial Infections 9.12 Conclusion References Additional Reading 10: Pharmacotherapy in Oral and Maxillofacial Surgery 10.1 Introduction 10.2 Antimicrobial Agents 10.2.1 Definition 10.2.2 Classification 10.2.3 Oral Microflora 10.2.4 Guidelines to the Therapeutic Use of Antibiotics 10.2.5 Consistency in Route of Administration 10.2.6 Cross-allerginicity between Penicillins & Cephalosporins 10.2.7 Patient Monitoring 10.3 General Considerations in the Prophylactic Use of Antibiotics 10.3.1 Prophylactic Uses of Antibiotics in Maxillofacial Surgery 10.3.2 Antibiotic Prophylaxis in the Surgical Removal of Wisdom Teeth 10.3.3 Antibiotic Prophylaxis in the Placement of Dental Implants 10.3.4 Antibiotic Prophylaxis in Orthognathic Surgery 10.3.5 Is Antibiotics Needed when Bone Plates and Screws Are Being Inserted? 10.3.6 Antibiotic Prophylaxis in Maxillofacial Trauma 10.3.7 Diabetes Mellitus & Antibiotic Prophylaxis in Maxillofacial Surgery 10.3.8 Antibiotic Prophylaxis in Head and Neck Oncology 10.3.9 Antibiotic Prophylaxis in Cleft Surgeries 10.3.10 Organ Transplant and Antibiotic Prophylaxis 10.4 Infective Endocarditis 10.5 Postoperative Pain Management in Maxillofacial Surgery 10.6 Pathophysiology of Postoperative Pain 10.6.1 Pre-Emptive Analgesia 10.6.2 Postoperative Pain Management 10.6.3 Pharmacological Management of Postoperative Pain 10.6.3.1 Opioids 10.6.3.2 Tramadol 10.6.3.3 Nonsteroidal Anti-Inflammatory Drugs (NSAIDs) 10.6.3.4 Paracetamol 10.6.4 Guidelines to the Use of Analgesics 10.6.4.1 Analgesic Ladder 10.6.4.2 Preventive /Protective/Multimodal Analgesia 10.6.4.3 Patient-Controlled Analgesia (PCA) 10.7 Corticosteroids in Maxillofacial Surgery 10.8 Conclusion References Additional Reading 11: Wound Closure and Care in Oral and Maxillofacial Surgery 11.1 Wound Management 11.2 Wound Closure 11.2.1 Purposes of Wound Closure 11.3 Wound Suturing 11.3.1 Suturing Instruments 11.3.1.1 Needle Holder 11.3.1.2 Tissue Holding Forceps 11.3.1.3 Suture Cutting Scissors 11.3.2 Suture Needles 11.3.2.1 Needle Shape 11.3.2.2 Needle Size 11.3.2.3 Eyed vs Swaged Needles 11.4 Suture Thread 11.4.1 Suture Thread Size 11.4.2 Natural Absorbable Sutures (Absorbed by Proteolysis) 11.4.2.1 Catgut 11.4.2.2 Chromic Catgut 11.4.3 Natural Non-absorbable Sutures 11.4.3.1 Cotton and Linen 11.4.3.2 Silk 11.4.4 Synthetic Non-absorbable Sutures 11.4.4.1 Polyamide/Nylon (Ethilon, Dermalon) 11.4.4.2 Polypropylene (Prolene, Surgipro) 11.4.4.3 Polyester (Ethibond, Surgidac, Dacron) 11.4.4.4 Polybutester (Novafil, Vascufil) 11.4.4.5 Polytetrafluroethylene (Gore-Tex, Cytoplast, Coreflon, Teflon) 11.4.4.6 Stainless Steel 11.4.5 Synthetic Absorbable Sutures (Absorbed by Hydrolysis) 11.4.5.1 Polyglycolic Acid (Dexon, PolySyn, PGA) 11.4.5.2 Polyglactin 910 (Vicryl, Polysorb) 11.4.5.3 Polydioxanone (PDS, PDO) 11.4.5.4 Poliglecaprone 25 (Monocryl/Biosyn/Petcryl Mono/Monoglyde) 11.4.5.5 Polyglyconate (Maxon) 11.4.5.6 Glycomer 631 (Biosyn) 11.4.5.7 Polyglytone 6211 (Caprosyn) 11.5 Knot-Tying 11.5.1 Two-Handed Tie 11.5.2 One-Handed Tie 11.5.3 Instrument Tie 11.6 Suture Knots 11.6.1 Square Knot/Reef Knot 11.6.2 Surgeon’s Knot 11.6.3 Granny’s Knot 11.7 Specific Suturing techniques [3] (Video 11.1) 11.7.1 Simple Interrupted Suture 11.7.2 Simple Buried Suture 11.7.3 Vertical Mattress Suture 11.7.4 Simple Continuous Suture 11.7.5 Locking Continuous Suture 11.7.6 Subcuticular Suture 11.7.7 Purse-String Suture 11.7.8 Three-Point Suture 11.7.9 Frost Suture 11.7.10 Drain Anchoring Suture 11.8 Dentoalveolar Suturing 11.8.1 Simple Interrupted Suture (Interdental Suture) 11.8.2 Interrupted Reversing Suture 11.8.3 Vertical Mattress Suture 11.8.4 Horizontal Mattress Suture 11.8.5 Horizontal Mattress Modification: Dental Anchor Suture 11.8.6 Horizontal Mattress Modification: Mattress Sling Suture 11.8.7 Horizontal Mattress Modification: Figure-of-Eight Suture (Cruciate Mattress Suture/Cross Suture) 11.8.8 Simple Continuous Suture 11.8.9 Continuous Locking Suture 11.9 Suture Removal 11.10 Other Wound Closure Methods 11.10.1 Staples 11.10.2 Tapes 11.10.3 Adhesives 11.11 Conclusion References 12: Postoperative Care of the Maxillofacial Surgery Patient 12.1 Assessment of the Patient After Surgery 12.1.1 Assessment of the Patient Immediately After Surgery 12.1.1.1 Care of the Airway 12.1.1.2 Need for Ventilation in the PACU 12.1.1.3 Monitoring in the PACU 12.1.1.4 Briefing the Patient and Family 12.1.1.5 Discharge from PACU to Ward 12.1.2 Comprehensive Assessment of the Patient in the Ward 12.1.2.1 Postoperative Investigations 12.2 Formulating a Plan of Care Based on Assessment 12.2.1 Fluid Therapy in the Postoperative Period 12.2.1.1 Types of Fluids Used 12.2.1.2 Strategy for Estimating Fluid Requirement 12.2.1.3 Liberal Versus Restrictive Fluid Therapy 12.2.1.4 Transfusion of Blood and Blood Products 12.2.2 Postoperative Medication 12.2.2.1 Pain Control 12.2.2.2 Anti-inflammatory Drugs 12.2.2.3 Antibiotic Prophylaxis 12.2.2.4 Medication to Prevent Postoperative Gastritis and Vomiting 12.2.2.5 Drugs for Thromboprophylaxis 12.2.2.6 Other Drugs That May be Required Based on the Patients’ Medical History 12.2.3 Nutritional Status in the Postoperative Period 12.2.4 Postoperative Mobilization of the Maxillofacial Surgery Patient 12.2.5 Management of Complications in the Postoperative Period 12.2.5.1 Sudden Airway Obstruction 12.2.5.2 Fever in the Postoperative Period 12.2.5.3 Changes in Pulse and Blood Pressure 12.2.5.4 Changes in Respiration 12.2.5.5 Postoperative Nausea and Vomiting 12.2.5.6 Oliguria and Acute Renal Failure 12.3 Care of the Surgical Wound Site 12.3.1 Immediate Care in the Operating Room 12.3.2 General Guidelines for Postoperative Wound Care [32] 12.3.3 Surgical Site Complications 12.4 Postoperative Care for Specific Types of Surgeries 12.5 Postoperative Complications Specific to each Type of Surgery 12.6 Criteria for Discharging the Patient 12.7 Conclusion References Part VI: Dentoalveolar and Oral Surgery 13: Principles and Techniques of Exodontia 13.1 Introduction 13.2 Definition 13.3 History 13.4 Applied Surgical Anatomy 13.4.1 Maxilla (Fig. 13.1) 13.4.2 Mandible (Fig. 13.2) 13.4.3 Teeth 13.5 Indications for Exodontia 13.6 Contraindications for Exodontia 13.6.1 Systemic Contraindications 13.6.2 Local Contraindications 13.7 Armamentarium for Exodontia [10, 11] 13.7.1 Forceps 13.7.2 Elevators 13.8 Sequential Procedure of Exodontia [6, 10] 13.8.1 Presurgical Assessment 13.8.2 Treatment Planning 13.8.3 Administration of Local Anesthesia 13.8.4 Surgeon and Patient Preparation 13.8.5 Position of Operator, Patient, and Chair 13.8.6 Exodontia Procedure 13.9 Various Mucoperiosteal Flap Designs for Transalveolar Extraction 13.10 Multiple Extractions 13.11 Extraction of Root Fragments and Tips 13.12 Extraction During Menstruation 13.13 Extraction During Pregnancy 13.14 Healing of Extraction Socket [15] 13.15 Complications of Exodontia [10] 13.16 Technological Advances in Exodontia Techniques [24] 13.16.1 Powered Periotome 13.16.2 Physics Forceps (Fig. 13.32) 13.16.3 Use of Implant Drills for Extraction Prior to Implant Placement 13.16.4 Use of LASER 13.16.5 Piezo Surgery 13.17 CASE Scenario References Articles for Additional Reading 14: Management of Impacted Third Molars 14.1 Introduction 14.1.1 Terminology 14.1.2 Incidence of Impaction 14.2 Management Techniques for the Impacted Tooth 14.2.1 Controversies on Prophylactic Removal of Third Molars 14.3 Etiology of Impaction 14.4 Indications for Removal 14.4.1 Relative Contraindications for Removal of Impacted Tooth 14.5 Surgical Anatomy 14.5.1 Neurovascular Bundle 14.5.2 Retromolar Triangle 14.5.3 Facial Artery and Vein 14.5.4 Lingual Nerve 14.5.5 Bone Trajectories of Mandible 14.5.6 Lingual Plate 14.6 Classification of Impacted Mandibular Third Molar 14.7 Preoperative Planning 14.7.1 Clinical Examination 14.7.2 Radiography of Impacted Mandibular Third Molar 14.7.2.1 Interpretation of Periapical X-ray 14.7.3 Lingual Nerve Protection and Injury 14.7.4 Preoperative Evaluation of Difficulty of Removal 14.8 Operative Procedure 14.8.1 Incision and Designing the Flap 14.8.2 Bone Removal 14.8.3 Elevation of Tooth from the Socket 14.8.4 Sectioning and Tooth Delivery 14.8.5 Modifications of standard technique 14.8.6 Debridement 14.8.7 Wound Closure 14.8.8 Other Methods for Removal/Partial Removal of Impacted Lower Third Molar 14.9 Impacted Maxillary Third Molar (Video 14.3) 14.9.1 Radiographic Examination 14.9.2 Indications for the Removal of Maxillary Third Molar 14.9.3 Adjacent Anatomical Factors to be Considered: (Fig. 14.33a–d) 14.9.4 Surgical Removal of Impacted Maxillary Third Molar (Figs. 14.35a–d and 14.36a, b) 14.9.4.1 Incision 14.9.4.2 Removal of Overlying Bone 14.9.4.3 Delivery of the Tooth 14.9.5 Complications That Occur During Surgical Removal of Impacted Maxillary Third Molar 14.10 Complications of Impaction Surgery References 15: Management of Impacted Canines 15.1 Introduction 15.2 Aetiology of Canine Impaction 15.3 Classification of Impacted Maxillary Canines 15.3.1 The Following Classification Suggested by Archer (1975) [2] is Very Practical 15.3.2 Field and Ackerman (1935) Classification [3] 15.4 Radiographic Localization of Impacted Canine 15.4.1 Radiographic Features to Consider 15.4.1.1 Parallax 15.4.1.2 OPG 15.4.1.3 Computed Tomography 15.4.1.4 Cone Beam CT 15.5 Modalities of Management of Impacted Canine 15.5.1 Surgical Exposure of Impacted Canines 15.5.1.1 Procedure 15.5.2 Surgical Removal of Palatally Impacted Maxillary Canines 15.5.2.1 Surgical Anatomy 15.5.2.2 Procedure (Fig. 15.7a–d) (Fig. 15.8a, b) 15.5.3 Surgical Removal of Labially Positioned Impacted Maxillary Canine (Fig. 15.9a, b) (Video 15.1) 15.5.3.1 Incision 15.5.3.2 Operative Procedure (Fig. 15.10a–f) (Fig. 15.11a–i) 15.5.4 Removal of Maxillary Canine in an Intermediate Position (Fig. 15.12a–h) 15.5.5 Management of Impacted Mandibular Canines 15.5.5.1 Treatment Options 15.5.5.2 Surgical Anatomy (Fig. 15.13) 15.5.5.3 Removal of Mandibular Canine (Figs. 15.14 and 15.15) 15.5.5.4 Complications of Surgical Removal 15.6 Summary References 16: Endodontic Surgery 16.1 Definition 16.2 Historical Frame of Reference 16.3 Indications for Endodontic Surgery [8] 16.3.1 Updated Indications (The European Society of Endodontology) (2006) [9] 16.4 Relative Contraindications 16.5 Preoperative Assessment and Planning 16.5.1 Anatomical Reflections 16.5.2 Important Considerations in the Maxilla and Maxillary Sinus 16.5.3 Important Considerations in the Mandible 16.6 Investigations 16.7 Anesthesia and Hemostasis 16.7.1 Premedication 16.7.2 Local Anesthesia and Sedation 16.8 Surgical Access 16.8.1 Armamentarium 16.8.2 Surgical Management 16.8.3 Basic Principles of Flap Design 16.8.4 Flap Elevation 16.8.5 Flap Retraction 16.8.6 Hard Tissue Management 16.8.7 Root end Preparation 16.8.7.1 Root end Resection (Fig. 16.12) 16.8.7.2 Root end Cavity Preparation 16.8.7.3 Root end Filling (Fig. 16.13) 16.9 Biology of Wound Healing [12] 16.10 Postoperative Complications 16.11 Outcome of Endodontic Surgery 16.12 Aids to Endodontic Surgery 16.12.1 Endoscopes 16.12.2 Dental Operating Microscope 16.13 Future Perspectives References Additional Reading (Algorithm for Periapical Surgery) 17: Preprosthetic Surgery 17.1 History 17.2 Pattern of Resorption 17.2.1 Types of Ridges 17.3 Treatment Planning 17.4 Ridge Correction Procedures 17.4.1 Alveoloplasty 17.4.2 Intercortical Alveoloplasty 17.4.3 Genial Tubercle Reduction 17.4.3.1 Procedure 17.4.4 Mylohyoid Ridge Reduction 17.4.4.1 Procedure 17.5 Maxillary Tuberosity Reduction 17.6 Torus Removal 17.6.1 Palatal Tori Removal 17.6.2 Lingual Torus 17.7 Exostosis 17.8 Excision of Reactive Inflammatory Papillary Hyperplasia 17.9 Frenectomy 17.9.1 Labial Frenectomy (Video 17.1) 17.9.2 Lingual Frenectomy (Video 17.2) 17.10 Ridge Extension Procedure 17.10.1 Vestibuloplasty [Sulcoplasty, Sulcus Extension] (Box 17.4) 17.10.2 Transpositional Flap Vestibuloplasty [Lip-Switch Procedure] 17.10.2.1 Procedure 17.10.3 Mandibular Vestibuloplasty with Grafting 17.10.3.1 Procedure 17.10.4 Lingual Vestibuloplasty: Anterior Region 17.10.4.1 Procedure 17.10.4.2 Lingual Vestibuloplasty: Posterior Region Trauner’s Technique [30] 17.10.4.3 Other Variations Include (Box 17.5) 17.11 Ridge Augmentation Procedures 17.11.1 Inferior Border Augmentation 17.11.2 Superior Border Augmentation 17.11.3 Interpositional Grafting 17.11.4 The Visor Osteotomy and Modified Visor 17.11.5 Graft Materials 17.11.6 Augmentation with Synthetic Graft Materials 17.12 Conclusion References Part VII: Dental Implantology 18: Basics of Dental Implantology for the Oral Surgeon 18.1 History and Evolution of Dental Implants 18.2 The Concept of Osseointegration 18.2.1 The Biological Process of Osseointegration 18.2.2 Assessment of Osseointegration 18.2.3 Factors that Determine Osseointegration 18.3 Comparison Between Implant and Tooth Surface [16] 18.4 Types of implants 18.5 Preoperative Examination of Potential Implant Patients 18.5.1 Clinical Examination 18.5.2 Radiographic Examination 18.5.3 Correct 3-Dimensional Position for an Implant 18.6 SAC Classification 18.7 Implant Solutions for Different Edentulous Situations 18.8 Timing of Implant Placement Postextraction 18.8.1 Hard and Soft Tissue Alterations Postextraction 18.8.2 Concept of Timing for Implant Placement 18.8.3 Healing Modality: Concept of Submerged and NonSubmerged Healing 18.9 Surgical Procedure for Conventional Implant Placement 18.10 Concepts of Implant Loading 18.11 Suggested Reading References 19: Bone Augmentation Procedures in Implantology 19.1 Introduction 19.2 The Alveolar Bone-Resorption Pattern and the Need for Augmentation 19.3 Bone Biology 19.3.1 Composition of Bone 19.4 Bone Grafts and Bone Substitutes 19.4.1 Classification of Bone Grafts Based on the Mechanism of Action 19.5 Barrier Membranes 19.5.1 Success Parameters of Autogenous Bone Graft Healing 19.6 Commonly Carried Out Augmentation Procedures 19.7 Guided Bone Regeneration 19.7.1 Augmentation of 2 and 3 Walled Defects 19.7.2 For Augmenting Apical Fenestrations 19.7.3 GBR for Ridge Preservation 19.7.4 GBR in Combination with Other Larger Augmentation Procedures 19.7.5 GBR for Contour Augmentation 19.8 Onlay Bone Grafting 19.8.1 Harvesting Bone from the Donor Site 19.8.1.1 Mandibular Ramus as the Donor Site 19.8.1.2 Chin (Anterior Mandible) as the Donor Site 19.8.1.3 Iliac Crest as the Donor Site 19.8.1.4 Calvarium as a Donor Site 19.8.2 Recipient Site Preparation and Completion of the Procedure 19.9 Sinus Floor Elevation 19.9.1 Classification and Treatment Options for the Posterior Edentulous Maxilla 19.9.2 Decision-Making: Lateral Versus Transcrestal Technique 19.9.3 Decision-Making: Simultaneous Versus Staged Approach 19.9.4 Transcrestal Surgical Technique 19.9.5 Lateral Window Technique 19.9.6 Complications Following Sinus Floor Elevation 19.10 Suggested Reading References Part VIII: Odontogenic Infections 20: Odontogenic Infections: General Principles 20.1 Introduction 20.2 Host Defense Mechanisms 20.3 The Infectious Microbes 20.4 Pathways of Odontogenic Infection 20.5 Pathways of Spread of Periapical Infections 20.6 Various Space Infections and Their Relative Severity 20.7 Basic Therapeutic Principles 20.8 Antimicrobial Therapy 20.9 Conclusion References 21: Fascial Space Infections 21.1 Introduction 21.2 Definition of Fascial Space 21.3 Spread of Infection 21.4 Classification of Spaces 21.4.1 Primary Spaces and Secondary Spaces 21.4.1.1 Cervical Spaces 21.4.1.2 Severity Score Anatomic Space [4] 21.5 General Priciples of Management of Infection 21.6 Hilton’s Method of Abscess Drainage (Figs. 21.1a and 21.1b) 21.7 Medical Management 21.7.1 Antibiotic Therapy 21.8 Fluid and Electrolytes 21.9 Selection of Anesthesia 21.10 Spaces Around the Maxilla 21.10.1 Canine Space/Infraorbital Space 21.10.1.1 Source of Infection 21.10.1.2 Boundaries (Fig. 21.2) 21.10.1.3 Contents 21.10.1.4 Clinical Features 21.10.1.5 Management 21.10.2 Buccal Space 21.10.2.1 Boundaries 21.10.2.2 Contents 21.10.2.3 Clinical Features 21.10.2.4 Management 21.10.3 Temporal Pouches 21.10.3.1 Superficial Temporal Space 21.10.3.2 Boundaries 21.10.3.3 Contents 21.10.3.4 Clinical Features 21.10.3.5 Management 21.10.4 Deep Temporal Space 21.10.4.1 Boundaries 21.10.4.2 Contents 21.10.4.3 Clinical Features 21.10.4.4 Management 21.11 Spaces Around the Mandible 21.11.1 Submental Space 21.11.1.1 Source of Infection 21.11.1.2 Boundaries (Fig. 21.7) 21.11.1.3 Contents 21.11.1.4 Clinical Features 21.11.1.5 Management 21.11.2 Sublingual Space 21.11.2.1 Source of Infection 21.11.2.2 Boundaries (Fig. 21.8) 21.11.2.3 Contents 21.11.2.4 Clinical Features 21.11.2.5 Management 21.11.3 Submandibular Space 21.11.3.1 Source of Infection 21.11.3.2 Boundaries 21.11.3.3 Contents 21.11.3.4 Clinical Features (Fig. 21.9) 21.11.3.5 Management 21.12 Masticator Space 21.12.1 Submasseteric Space 21.12.1.1 Source of Infection 21.12.1.2 Boundaries 21.12.1.3 Clinical Features 21.12.1.4 Management 21.12.2 Pterygomandibular Space 21.12.2.1 Source of Infection 21.12.2.2 Boundaries 21.12.2.3 Contents 21.12.2.4 Clinical Features (Fig. 21.13) 21.12.2.5 Management Intraoral Approach Extraoral Approach 21.13 Spaces of Neck 21.13.1 Parapharyngeal Spaces 21.13.2 Lateral Pharnygeal Space 21.13.2.1 Source of Infection 21.13.2.2 Boundaries 21.13.2.3 Contents 21.13.2.4 Clinical Features 21.13.2.5 Management 21.13.3 Retropharyngeal Space 21.13.3.1 Source of Infection 21.13.3.2 Boundaries 21.13.3.3 Contents of the Space 21.13.3.4 Clinical Features 21.13.3.5 Management 21.13.4 Peritonsillar Abscess: (Quincy) 21.13.4.1 Source of Infection 21.13.4.2 Boundaries 21.13.4.3 Clinical Features 21.13.4.4 Management 21.14 Sequelae of Space Infections, if Ignored 21.14.1 Ludwig’s Angina 21.14.1.1 Source 21.14.1.2 Predisposing Factors 21.14.1.3 Clinical Features (Table 21.6) 21.14.1.4 Management 21.14.2 Necrotizing Fasciitis 21.14.2.1 Source 21.14.2.2 Clinical Features (Table 21.7) 21.14.2.3 Investigations 21.14.2.4 Management 21.14.3 Cavernous Sinus Thrombosis 21.14.3.1 Source 21.14.3.2 Clinical Features 21.14.3.3 Eagleton Criteria 21.14.3.4 Management 21.14.4 Meningitis 21.14.4.1 Clinical Features 21.14.4.2 Diagnosis 21.14.4.3 Treatment 21.15 Conclusion References Additional Suggested Reading 22: Osteomyelitis, Osteoradionecrosis, and Medication-Related Osteonecrosis of Jaws 22.1 Introduction 22.1.1 Osteoblasts 22.1.2 Osteocyte 22.1.3 Osteoclast 22.1.4 RANK RANKL OPG 22.2 Osteomyelitis 22.2.1 Definition 22.2.2 Classification 22.2.3 Epidemiology 22.2.4 Etiology 22.2.5 Pathogenesis 22.2.6 Histology 22.2.7 Symptoms 22.2.8 Complications 22.2.9 Diagnosis 22.2.10 Differential Diagnoses 22.2.11 Therapy 22.2.12 Prognosis 22.3 Osteoradionecrosis 22.3.1 Definition 22.3.2 Epidemiology 22.3.3 Etiology 22.3.4 Pathogenesis 22.3.5 Classification 22.3.6 Histology 22.3.7 Symptoms 22.3.8 Complications 22.3.9 Diagnosis 22.3.10 Differential Diagnoses 22.3.11 Therapy 22.3.12 Prognosis 22.3.13 Prevention 22.4 Medication-Associated Osteonecrosis of the Jaws 22.4.1 Bisphosphonate-Associated Osteonecrosis of the Jaws 22.4.1.1 Bisphosphonates 22.4.1.2 Definition 22.4.1.3 Epidemiology 22.4.1.4 Etiology 22.4.1.5 Pathogenesis 22.4.1.6 Classification 22.4.1.7 Histology 22.4.1.8 Symptoms 22.4.1.9 Complications 22.4.1.10 Diagnosis 22.4.1.11 Differential Diagnosis 22.4.1.12 Therapy 22.4.1.13 Prognosis 22.4.1.14 Prevention 22.4.2 Osteonecrosis of the Jaws Due to Other Medications but Bisphosphonates 22.4.2.1 Denosumab 22.4.2.2 Sunitinib 22.4.2.3 Imatinib 22.4.2.4 Bevazicumab 22.4.2.5 Ziv-aflibercept 22.4.2.6 Everolimus 22.4.2.7 Corticosteroids 22.4.2.8 Crystal Meth References Part IX: Maxillary Sinus and the Oral Surgeon 23: Maxillary Sinusitis 23.1 Introduction 23.2 Anatomy of Maxillary Sinus 23.3 Maxillary Sinus Physiology 23.4 Sinusitis Pathophysiology 23.4.1 Microorganisms of Sinusitis 23.5 Predisposing Factors 23.5.1 Anatomical Variation 23.5.2 Atopy (Allergy) 23.5.3 Asthma 23.5.4 Aspirin 23.5.5 Environmental 23.5.6 Ciliary Impairment 23.5.7 Smoking 23.5.8 Gastro-Oesophageal Reflux 23.5.9 Odontogenic Maxillary Sinusitis 23.6 Classification of Sinusitis 23.6.1 Acute Rhinosinusitis 23.6.2 Chronic Rhinosinusitis 23.6.3 Fungal Rhinosinusitis 23.7 Clinical Diagnosis 23.8 Clinical Imaging 23.9 Treatment 23.9.1 Conservative Management 23.9.2 Medical Management 23.9.2.1 Nasal Decongestants 23.9.2.2 Topical Nasal Glucocorticosteroids 23.9.2.3 Systemic Glucocorticosteroids 23.9.2.4 Antimicrobial Therapy 23.9.3 Surgery 23.9.3.1 Surgical Method: Caldwell-Luc Approach 23.9.3.2 Complications with Caldwell-Luc approach 23.9.3.3 Surgical Method: Functional Endoscopic Sinus Surgery 23.9.3.4 Complications with the FESS Approach 23.10 Conclusion References 24: OroAntral Communications and OroAntral Fistula 24.1 Introduction 24.2 Aetiology of OAC 24.3 Clinical Features of OAC 24.3.1 Radiological Features of OAC 24.3.2 Management of OAC 24.4 OroAntral Fistula 24.4.1 Aetiology of OAF 24.4.2 Clinical Features 24.4.3 Confirmatory Tests of OAF 24.4.4 Treatment Modalities for OAF 24.4.5 Assessment of OAF 24.4.6 Objectives in Treatment of OAF 24.5 The Buccal Advancement Flaps 24.5.1 Step-by-Step Technique of Doing Buccal Advancement Flap + Buccal Fat Pad Grafting (BFP) 24.5.2 Clinical Pictures Demonstrating 2 Layer Closure Technique with BFP (Fig. 24.14a, b, c, d and e) [50] 24.6 Palatal Rotational Flap (Ashley’s Flap) 24.7 Importance of Timing of Closure of OAF 24.7.1 Role of Health of Sinus and Antral Regime 24.7.2 The Antral Regime 24.7.3 Antral Lavage 24.8 Caldwell Luc Procedure 24.9 OAF with Chronic Sinusitis 24.10 Nasal Antrostomy 24.11 Root in Sinus 24.11.1 Policy of Leaving Root Tip In Situ 24.12 Conclusion References Part X: Nerve Injuries and Neuralgias of Oral and Maxillofacial Region 25: Trigeminal Nerve Injuries 25.1 Local Anaesthetic-related Nerve Injuries 25.1.1 Avoiding Block Anaesthesia by Using Infiltration Dentistry 25.2 Management of LA Nerve Injuries 25.3 Implant-related Nerve Injuries 25.4 Mandibular Third Molar Extraction-related Nerve Injuries 25.4.1 Risk Assessment 25.4.2 Patient Factors 25.4.3 Anatomical 25.4.4 Radiological Factors 25.4.5 Surgical 25.5 LN Injury Risk Factors 25.6 Role of Alternative Surgical Techniques 25.7 Prognosis of Nerve Injuries (Table 25.4) [43] 25.8 Conclusions References 26: Trigeminal Neuralgia 26.1 Introduction 26.2 Anatomy of the Trigeminal Nerve 26.2.1 Peripheral Distribution of Trigeminal Nerve (Fig. 26.2 and Table 26.1) 26.3 Aetiology of Trigeminal Neuralgia 26.3.1 Neurovascular Compression 26.3.2 Multiple Sclerosis (MS) 26.3.3 Tumour and Cyst 26.3.4 Diabetes Mellitus 26.3.5 Herpes Simplex 26.4 Pathophysiology of TN 26.5 Historical Perspective 26.6 Clinical Presentation 26.6.1 Risk Factors 26.6.1.1 Initiating Factors 26.6.2 Prevalence 26.6.3 Clinical Diagnosis 26.6.3.1 Pain History 26.6.3.2 Other Causes 26.6.4 Glossopharyngeal Neuralgia 26.7 Investigations 26.8 Management 26.8.1 Medical Management 26.8.1.1 Carbamazepine and Oxcarbazepine 26.8.1.2 Gabapentin 26.8.1.3 Baclofen 26.8.1.4 Lamotrigine 26.8.1.5 Evolving Medical Therapy 26.8.2 Surgical Management 26.8.2.1 Microvascular Decompression (MVD) 26.8.2.2 Gamma Knife Radiosurgery (GKRS) 26.8.2.3 Percutaneous Balloon Compression (PBC) 26.8.2.4 Radiofrequency Thermocoagulation (RFTC) 26.8.2.5 Glycerol Rhizotomy 26.9 Peripheral Nerve Procedures 26.9.1 Infraorbital Neurectomy 26.9.2 Inferior Alveolar Nerve or Mental Nerve Neurectomy 26.9.2.1 Inferior Alveolar Neurectomy via Ginwala’s Access [103] (Video 26.1) 26.9.3 Cryotherapy 26.9.4 Alcohol Block 26.9.5 Other Peripheral Procedures 26.10 Conclusion References Part XI: Benign Pathologies of the Oral and Maxillofacial Region 27: Cysts of the “Oro-Maxillofacial Region” 27.1 Introduction 27.2 Definition 27.3 General Histopathological Common Components of a Cyst 27.4 Etiopathogenesis 27.4.1 Theories of Cyst Enlargement/Expansion 27.4.1.1 Mural Growth & Peripheral Cell Division 27.4.1.2 Hydrostatic Enlargement Biomechanical Theory 27.4.1.3 Bone Resorbing Factor Biochemical and Cellular Aspects of the Cyst Proliferation 27.5 Historical Evolution of the WHO Classification Systems 27.6 Prevalence of Cysts 27.7 General Key Attributes Regarding an Oro-maxillo-Facial Cyst-Signs & Symptoms (Boxes 27.2 and 27.3) 27.7.1 Vitality Test of the Involved Teeth in the Lesion 27.7.2 Radiographic Examination 27.7.2.1 General Radiographic Picture 27.7.2.2 Radiological Classification of Jaw Cysts (Shear) [1] 27.7.3 Aspiration 27.7.4 Cystic Fluids 27.7.4.1 Biochemical Analysis of the Cystic Fluid 27.7.5 Biopsy 27.8 Various Surgical Treatment Modalities for Cystic Lesion 27.8.1 Conventional Surgical Options 27.8.1.1 Decompression 27.8.1.2 Marsupialization 27.8.2 Modification of Marsupialization-Waldron’s Method—Two-Staged Procedure [17] 27.8.3 Enucleation or Cystectomy or Partsch II (Videos 27.1 and 27.2) 27.8.3.1 Surgical Procedure 27.8.3.2 Enucleation Along with the Adjunct Procedures 27.8.3.3 Enucleation Followed by Bone Grafting 27.8.4 Block Resection, With or Without Preservation of the Continuity of the Jaw 27.9 Dentigerous Cysts or Follicular Cysts 27.9.1 Differential Diagnosis 27.9.2 Histology 27.9.3 Potential Complications of Dentigerous Cyst 27.10 Odontogenic Keratocyst 27.10.1 Etiology and Pathogenesis 27.10.2 Unique Growth Pattern—Peculiar Behavior—Pattern of Bone Involvement in OKC 27.10.3 Radiographic Differential Diagnosis 27.10.4 Aspiration 27.10.5 Surgical Treatment 27.10.5.1 Resection 27.10.6 Basal Cell Nevus Syndrome/Nevoid Basal Cell Carcinoma Syndrome 27.11 Conclusion References 28: Benign Odontogenic Tumours 28.1 Introduction 28.2 WHO (2017) Classification of Odontogenic Tumours [5] 28.2.1 Benign Odontogenic Tumours 28.2.1.1 Epithelial Origin 28.2.1.2 Mixed (Epithelial-Mesenchymal) Origin 28.2.1.3 Mesenchymal Origin 28.2.2 Malignant Odontogenic Tumours 28.3 Ameloblastoma 28.3.1 Introduction 28.3.2 Definition 28.3.3 Incidence 28.3.4 Clinical Features 28.3.5 Radiological Features 28.4 Solid/Multicystic Ameloblastoma 28.4.1 The Treatment Goals 28.4.1.1 Indications of Enucleation and Curettage 28.4.2 Surgical Management of Ameloblastoma According to the Anatomic Locations 28.4.2.1 Mandibular Anterior Region (Canine to Canine) 28.4.2.2 Posterior Mandible (Bicuspid to Condyle) 28.4.2.3 Anterior Maxilla (Canine to Canine) 28.4.2.4 Posterior Maxilla (Bicuspid to Pterygoid Plates) 28.5 Reconstructive Modalities After Surgical Resection of  Ameloblastoma 28.5.1 Timing of Reconstruction 28.5.1.1 Case Scenario 1 (Fig. 28.3a–g) 28.5.2 Bone Graft Substitutes 28.6 Unicystic-Type Ameloblastoma 28.6.1 Clinical and Radiographic Features 28.6.1.1 Case Scenario 2 (Fig. 28.4a, b) 28.6.2 Management 28.7 Use of Carnoy’s Solution in Ameloblastomas 28.7.1 Case Scenario 3 (Fig. 28.6a–i) 28.7.2 Case Scenario 4 (Fig. 28.7a–f) 28.8 Extraosseous/Peripheral Ameloblastoma (PA) 28.8.1 Differential Diagnosis 28.9 Metastasising (Malignant) Ameloblastoma 28.10 Squamous Odontogenic Tumours 28.10.1 Introduction 28.10.2 Definition 28.10.3 Clinical Features [71] 28.10.4 Radiographic Features [72] 28.10.5 Treatment and Prognosis 28.11 Calcifying Epithelial Odontogenic Tumour 28.11.1 Definition 28.11.2 Epidemiology 28.11.3 Clinical Features 28.11.4 Radiographic Features 28.11.5 Treatment 28.12 Adenomatoid Odontogenic Tumour 28.12.1 Definition [85] 28.12.2 Clinical Features 28.13 Mixed (Epithelial-Mesenchymal) Origin 28.13.1 Ameoblastic Fibroma 28.13.1.1 Clinical Features 28.13.1.2 Radiographic Features 28.13.2 Odontoma (Compound, Complex Types) 28.14 Mesenchymal Origin Tumours 28.14.1 Odontogenic Myxoma 28.14.1.1 Clinical Features 28.14.1.2 Treatment and Prognosis 28.14.2 Cementoblastoma 28.15 Recent Advances 28.16 Case Scenario 5 (Fig. 28.9a–j) 28.17 Conclusion References Additional Reading 29: Reactive Lesions of Oro-Maxillofacial Region 29.1 Introduction 29.2 Classification 29.3 Pyogenic Granuloma 29.3.1 Clinical Features and Aetiopathogenesis 29.3.2 Differential Diagnosis 29.3.3 Diagnostic Workup 29.3.4 Recent Concepts 29.3.5 Treatment 29.3.6 Prognosis 29.4 Peripheral Giant Cell Granuloma 29.4.1 Clinical Features and Aetiopathogenesis 29.4.2 Differential Diagnosis 29.4.3 Radiologic Features 29.4.4 Histopathological Features 29.4.5 Treatment 29.4.6 Prognosis and Complications 29.4.7 Recent Advances 29.5 Peripheral Ossifying Fibroma 29.5.1 Clinical Features and Aetiopathogenesis 29.5.2 Differential Diagnosis 29.5.3 Radiologic Features 29.5.4 Histopathologic Features (Fig. 29.4c) 29.5.5 Treatment 29.5.6 Prognosis and Complications 29.6 Central Giant Cell Granuloma (Figs. 29.5 and 29.6) 29.6.1 Introduction 29.6.2 Clinical Features and Aetiopathogenesis 29.6.3 Differential Diagnosis 29.6.4 Radiological Features 29.6.5 Histopathologic Features 29.6.6 Treatment 29.7 Aneurysmal Bone Cyst (Fig. 29.7a–f) 29.7.1 Clinical Features 29.7.2 Aetiopathogenesis 29.7.3 Radiologic Features 29.7.4 Histopathological Features 29.7.5 Treatment 29.7.6 Prognosis and Complications 29.8 Brown Tumour of Hyperparathyroidism (Fig. 29.8) 29.8.1 Etiopathogenesis 29.8.2 Clinical Features 29.8.3 Diagnostic Workup 29.8.4 Differential Diagnosis 29.8.5 Radiographic Features 29.8.6 Histopathology 29.8.7 Treatment 29.8.8 Prognosis 29.9 Chronic Sclerosing Osteomyelitis and Garre’s Osteomyelitis 29.10 Conclusion Case Scenario 1 (Fig. 29.5) Case Scenario 2 (Fig. 29.6a–d) Case Scenario 3 (Fig. 29.7) Case Scenario 4 (Fig. 29.8) References Reactive Lesions of Oro-facial Soft Tissues Central Giant Cell Granuloma Aneurysmal Bone Cyst Brown Tumor 30: Fibro-osseous Lesions in the Maxillofacial Region 30.1 Introduction 30.2 Classifications 30.2.1 Waldron’s Classification, 1985 [5, 10] 30.2.2 WHO Classification of FOLs, 2005 [8] 30.2.3 Speight and Carlos Classification (2006) [9] 30.2.4 Eversole Classification, 2008 [1] 30.3 Fibrous Dysplasia (FD) 30.3.1 Clinical Features 30.3.2 Radiographic Features 30.3.3 Histological Features 30.3.4 Treatment and Prognosis 30.4 Ossifying Fibroma/Cementifying Fibroma/Cemento-Ossifying Fibroma (COF) and Juvenile (Aggressive)-Ossifying Fibroma 30.4.1 Clinical Features 30.4.2 Radiological Features 30.4.3 Histologic Features 30.4.4 Treatment and Prognosis 30.5 Cemento-Osseous Dysplasia (Osseous Dysplasia) 30.6 Periapical Cemento-Osseous Dysplasia 30.6.1 Clinical, Radiological and Histological Presentation 30.7 Focal Cemento Osseous Dysplasia 30.7.1 Clinical, Radiological and Histopathological Features 30.8 Florid Cemento-Osseous Dysplasia 30.8.1 Clinical, Radiological and Histological Features 30.8.2 Treatment/Management 30.9 Conclusion References 31: Vascular Anomalies of the Oro-Maxillofacial Region 31.1 Introduction 31.2 Pathogenesis 31.3 Classifications 31.4 Clinical Findings (Table 31.4) 31.5 Radiological Assessment 31.6 Medical and Interventional Management 31.7 Surgical Management 31.7.1 Surgical Anatomy 31.7.2 Case Selection 31.7.3 Technique of External Carotid Artery (ECA) Control (Fig. 31.24) 31.7.4 Corset-Suturing Technique (Fig. 31.25) 31.7.5 Approaches and Excision/Debulking 31.8 Complications 31.9 Recent Advances 31.10 Conclusion References Part XII: Aesthetic Procedures in Oral and Maxillofacial Region 32: Non-surgical Modalities of Facial Rejuvenation and Aesthetics 32.1 Introduction to Ageing Face 32.1.1 Facial Changes Due to Ageing 32.1.2 Ageing of Skin 32.1.3 Ageing of Subcutaneous Tissue 32.1.4 Ageing of SMAS 32.1.5 Ageing of Facial Skeleton 32.2 Non-surgical Facelift with Threads 32.2.1 Introduction to Thread Lift 32.2.2 Classification 32.2.3 Mechanism of Action 32.2.4 Indications 32.2.5 Treatment Protocol [4] 32.2.6 Procedure 32.2.7 Complications and Management 32.2.8 Conclusion 32.3 Biostimulatory Lift with Platelet-Rich Plasma 32.3.1 Platelets and Platelet Concentrates 32.3.2 Mechanism of Action of PRP 32.3.3 Indications of PRP Therapy in Aesthetic Medicine 32.3.4 Preparation of PRP 32.3.5 PRP Injections for Facial Rejuvenation, Biostimulatory Lift and Acne Scar 32.3.6 Contraindications to PRP Therapy [26] 32.3.7 Conclusion 32.4 Face Tightening with HIFU (High Intensity Focussed Ultrasound) 32.4.1 Introduction to HIFU 32.4.2 Mechanism of Action 32.4.3 Armamentarium 32.4.4 Indications and Contraindications in Facial Aesthetics 32.4.5 Procedure for Face Tightening 32.4.5.1 Facial Rejuvenation - HIFU (Video 32.1) 32.4.6 Adverse Effects 32.4.7 Conclusion 32.5 Skin Tightening with Radiofrequency 32.5.1 Principle of Action 32.5.2 Armamentarium 32.5.3 Indications 32.5.4 Advantages 32.5.5 Procedure of RF for Face 32.6 Conclusion 32.7 Case Scenarios 32.7.1 Patient 1 (Fig. 32.25a–d) 32.7.2 Patient 2 (Fig. 32.26a–g) References 33: Botulinum Toxin and Fillers for Maxillofacial Esthetics 33.1 Introduction 33.1.1 Facial Aesthetics 33.1.2 Facial Skin Physiology, Muscular Anatomy and Mechanical Properties 33.1.3 Facial Muscles and Their Actions (Fig. 33.1) 33.2 Botulinum Toxin 33.2.1 Botulinum Toxin-Type A 33.2.2 Pharmacology and Mechanism of Action 33.2.3 Indications 33.2.3.1 Contraindications [10] 33.2.4 Injection Techniques (Video 33.1) 33.2.5 Complications and Recommendations While Using Botulinum Toxin 33.3 Dermal Fillers 33.3.1 Role of Fillers in Facial Aesthetics 33.3.2 Classification of Fillers 33.3.3 Dermal Filler Injection Methods (Fig. 33.12) 33.3.4 Injection Techniques 33.3.5 Contraindication [22] 33.4 Conclusion Case Scenarios Case 1 (Fig. 33.18a,b,c) Case 2 (Fig. 33.19a,b,c) References 34: Hair Transplantation 34.1 Introduction 34.2 Surgical Anatomy 34.2.1 Blood Supply and Sensory Innervation 34.2.2 Zones of the Scalp 34.2.3 Microanatomy of Hair 34.3 Terminology 34.4 Growth Cycle and Hair Loss 34.5 Classification 34.5.1 Norwood Classification (Fig. 34.4) 34.5.2 Classification of Hair Loss in Women 34.6 Medications for Hair Loss 34.6.1 Minoxidil 34.6.2 Finasteride 34.6.3 Cyclical Therapy 34.7 Clinical Consultation 34.8 Concept of Hair Transplantation 34.9 Techniques and Description 34.9.1 Follicular Unit Transplantation (FUT) (Box 34.3) (Video 34.1) 34.9.1.1 Assessment of the Donor Hair 34.9.1.2 Donor Site Preparation and Anaesthesia 34.9.1.3 Preparation of Local Anaesthesia 34.9.1.4 Instruments for the Strip Procedure 34.9.1.5 Trichophytic Closure 34.9.1.6 Slivering 34.9.2 Follicular Unit Extraction (FUE) (Box 34.4) (Video 34.2) 34.9.2.1 Blades 34.9.2.2 Needles 34.9.2.3 Limitations of Follicular Unit Extraction 34.9.2.4 Hairline (Fig. 34.18a, b) 34.9.2.5 The Recipient Sites Preparation and Implantation 34.9.2.6 Implanters 34.9.3 Combi Technique (Fig. 34.23) 34.10 Post-operative Care 34.11 Complications 34.11.1 Complications in Preoperative Phase 34.11.2 Complications in Surgical Phase 34.11.3 Post Surgical Complications 34.12 Current Advances 34.13 Role of a Maxillofacial Surgeon 34.14 Conclusion 34.15 Case Scenarios Case Scenario 1 (Fig. 34.26) Case Scenario 2 (Fig. 34.27) References 35: Ear Reconstruction 35.1 Introduction 35.2 Incidence and Etiology 35.3 Surgical Anatomy 35.4 Classification 35.5 Evaluation and Management 35.6 Timing 35.7 History 35.8 Principle and Planning (Video 35.1) 35.9 Simulation Training 35.10 Template 35.11 Auricular Reconstruction Using Autologous Rib Cartilage 35.11.1 Harvesting Rib Cartilage 35.11.2 Framework 35.11.3 Skin Pocket 35.11.4 Second Stage 35.11.5 Complications 35.12 Auricular Reconstruction Using Alloplast 35.12.1 Technique 35.12.2 Complications 35.13 Prosthetic Ear 35.13.1 Retention of the Prosthesis 35.13.2 Prosthetic Technique 35.14 Future 35.15 Conclusion 35.16 Case Scenarios References Additional Reading 36: Management of Facial Scars 36.1 Introduction 36.2 Pathophysiology 36.3 Scar Management 36.3.1 General Principles 36.3.2 Non-surgical Remedies 36.4 Surgical Scar Management 36.4.1 Basic Principles 36.4.2 Surgical Technique 36.5 Future 36.6 Conclusion 36.7 Case Scenarios Case Scenario 1 (Fig. 36.1) Case Scenario 2 (Fig. 36.8) References 37: Surgical Facelift 37.1 Introduction 37.2 Historical Perspective 37.3 Anatomy of Ageing Face 37.4 Standard Facelift 37.4.1 Incision 37.4.2 Dissection 37.4.3 SMAS and Platysmal Elevation and Plication 37.4.4 Closure 37.4.5 Support Dressings 37.5 Post-operative Management 37.6 Complications and Management 37.6.1 Haematoma 37.6.2 Skin Ischaemia and Necrosis 37.6.3 Obvious Scarring 37.6.4 Sensory Disturbances 37.6.5 Motor Nerve Disturbances 37.6.6 Ear Lobe Irregularities 37.7 Conclusion 37.8 Case Scenarios Case Scenario 1 (Fig. 37.26) Case Scenario 2 (Fig. 37.27) References 38: Rhinoplasty 38.1 Introduction 38.2 Surgical Anatomy of the Nose 38.2.1 External Nose 38.2.2 Internal Anatomy 38.2.3 Nasal Septum 38.2.4 Lateral Nasal Wall 38.3 Clinical Examination 38.3.1 Examination of the Face 38.3.2 Examination of the Nose 38.3.3 Photographic Assessment 38.3.4 Investigations 38.4 General Operative Techniques 38.4.1 Surgical Approaches for Rhinoplasty 38.4.2 Grafting in Rhinoplasty 38.4.3 Septoplasty 38.4.3.1 Deformities of Nasal Septum 38.4.3.2 Sequencing for Treatment 38.4.3.3 Surgical Approaches 38.4.3.4 Surgical Technique (Fig. 38.19a, b, c) 38.4.4 Nasal Osteotomies 38.4.4.1 Indications for Nasal Osteotomies 38.4.4.2 Armamentarium for Nasal Osteotomies 38.4.4.3 Surgical Technique 38.5 Surgical Management of Basic Nasal Deformities 38.5.1 Dorsal Hump Deformity 38.5.1.1 Types of Dorsal Humps 38.5.1.2 Clinical Assessment of a Dorsal Hump (Fig. 38.22a–d) 38.5.1.3 Armamentarium for Dorsal Hump Reduction 38.5.1.4 Dorsal Hump Reduction (Profile Lowering) 38.5.1.5 Complications 38.5.1.6 Preservation Technique of Hump Removal (Regnault & Daniel) 38.5.2 Saddle Nose Deformity 38.5.2.1 Classification 38.5.2.2 Clinical Features 38.5.2.3 Surgical Management (Fig. 38.25a, b) 38.5.3 Correction of the Deviated Nose 38.5.3.1 Aetiology 38.5.3.2 Clinical Features 38.5.3.3 Treatment (Fig. 38.26a–g) 38.5.4 Tip Plasty 38.5.4.1 Wide Nasal Tip 38.5.4.2 Bulbous/Boxy Tip (Fig. 38.29) 38.5.4.3 Overprojected Nasal Tip (Fig. 38.30a–c) 38.5.4.4 Underprojected Tip (Fig. 38.31a, b) 38.5.4.5 Over-Rotated Tip (Piggy Nose) (Fig. 38.32b) 38.5.4.6 Under-Rotated Tip (Ptotic Nasal Tip) (Fig. 38.32a) 38.5.5 Managing the Wide Ala 38.5.5.1 Causes of Variations in Alar Base Width 38.5.5.2 Clinical Features 38.5.5.3 Evaluation 38.5.5.4 Surgical Treatment (Fig. 38.33a, b) 38.5.6 Septal Perforations 38.5.6.1 Clinical Features 38.5.6.2 Investigations 38.5.6.3 Treatment 38.5.7 Nasal Valve Problems 38.5.7.1 Anatomy of the Nasal Valves 38.5.7.2 Clinical Examination of Nasal Valve Problems 38.5.7.3 Surgical Management 38.6 Complications Following Rhinoplasty 38.7 Conclusion References Additional Reading Part XIII: Advances in Oral and Maxillofacial Surgery 39: Lasers in Oral and Maxillofacial Surgery 39.1 Introduction 39.2 Laser Physics 39.2.1 Advantages of Laser 39.2.2 Disadvantages of Laser 39.3 Selection of Lasers 39.4 Applications of Lasers in Oral and Maxillofacial Surgery 39.5 Specific Examples of Application of Lasers in Oral and Maxillofacial Surgery 39.6 Safety Concerns with Use of Lasers 39.7 Conclusion References 40: Piezosurgery in Oral and Maxillofacial Surgery 40.1 Introduction 40.2 Equipment and Principles of Use 40.3 Advantages 40.4 Disadvantages/Limitations 40.5 Applications for Piezosurgery 40.5.1 Dentoalveolar Procedures 40.5.2 Dental Implant Surgery 40.5.2.1 Sinus Floor Elevation 40.5.2.2 Implant Site Preparation 40.5.2.3 Alveolar Ridge Splitting 40.5.2.4 Lateralization of the Inferior Alveolar Nerve 40.5.3 Bone Graft Harvesting 40.5.4 Orthognathic Surgery 40.5.5 Aesthetic Facial Surgery 40.5.6 Distraction Osteogenesis 40.5.7 Temporomandibular Joint Surgeries 40.5.8 Inferior Alveolar Nerve Preservation 40.5.9 Trauma 40.6 Conclusion References 41: Computer-Assisted Navigation Surgery in Oral and Maxillofacial Surgery 41.1 Introduction 41.2 Medical Navigation Technology 41.2.1 Differences Between Optical and Electromagnetic Tracking Systems 41.2.2 Registration Techniques 41.2.3 Application to Oral-Maxillofacial Surgery 41.2.3.1 Application to the Maxilla and Midface 41.2.3.2 Application to the Mandible 41.3 Clinical Significance in Oral and Maxillofacial Surgery 41.3.1 Application for Oral-Maxillofacial Trauma 41.3.2 Application for Oral-Maxillofacial Tumor/Cancer 41.3.3 Application for Orthognathic Surgery 41.3.4 Application for Preimplant Bone Augmentation/Dental Implants 41.3.5 Clinical Applications for the Removal of Foreign Bodies 41.3.6 Application for Dentoalveolar Surgery 41.3.7 Application for Temporomandibular Joint and Skull Base Surgery 41.3.8 Other Applications 41.4 Recent Advances 41.4.1 Navigation Using Intraoperatively Updated Images 41.4.2 Wearable Mount Display for Navigation-Assisted Surgery 41.5 Conclusions and Perspectives References Part XIV: Practice Management in Oral and Maxillofacial Surgery 42: Human Factors Recognition to Enhance Team Working and Safer Patient Care 42.1 Introduction 42.2 The Scale of the Problem 42.3 How Do Human Errors Arise? 42.3.1 Senior Management Support Is Essential in Helping to Reduce Medical Error 42.3.2 Human Factors That We Should Be Thinking About 42.3.2.1 Fatigue and Tiredness 42.3.2.2 Nutritional Status and Hydration 42.3.2.3 Stress and Emotions While We Are Working 42.4 What About WHO and Other Checklists and Team Working Dynamics on Surgical Performance? 42.5 Situational Awareness 42.6 HF Training When Not in the Operating Theatre 42.7 Conclusion References 43: De Novo Practice of Oral and Maxillofacial Surgery 43.1 Introduction 43.2 Professional Skill and Learning 43.2.1 Kolb’s Learning Cycle [7] 43.2.2 Transformative Learning Way 43.2.3 Intra-operative Educating 43.3 Career Goals 43.4 De Novo Practice 43.4.1 Requirements 43.4.2 Types of Practice 43.4.3 Qualities Needed 43.4.3.1 Strategic Planning 43.4.3.2 Technique Formulation TOWS Matrix Analysis 43.4.3.3 Operational Planning 43.4.3.4 Assessment of Results 43.4.3.5 Marketing Oral and Maxillofacial Surgery [20] 43.4.3.6 Staff Hiring 43.4.3.7 Communication 43.4.3.8 Record Keeping 43.4.3.9 Reformulating the Strategy 43.4.3.10 Professional and Financial Growth in Career 43.4.3.11 Time Management (Fig. 43.4b) 43.4.3.12 Management of Finances (Fig. 43.4c) 43.5 Conclusion References 44: Medicolegal Issues in Maxillofacial Surgery 44.1 Introduction 44.2 What Are the Legal Issues That Must Concern the Maxillofacial Surgeon? 44.3 Scope of Practice of Maxillofacial Surgery as per the Indian Law 44.3.1 Historical Perspective 44.3.2 Current Legal Privileges 44.4 Legal Requirements to Be Followed When Dealing With a Patient 44.4.1 Informed Consent 44.4.1.1 Definition and Principles of Informed Consent 44.4.1.2 History and Theory of Informed Consent [15] 44.4.1.3 Types of Informed Consent [17] 44.4.1.4 Informed Consent in Oral and Maxillofacial Surgery 44.4.1.5 Informed Consent and Negligence in Oral and Maxillofacial Surgery 44.4.1.6 Informed Consent for Clinical Trials and New Techniques 44.4.2 Dentist/Maxillofacial Surgeons as Expert Witnesses 44.5 Medical Negligence in Maxillofacial Surgery 44.5.1 What Is Negligence? 44.5.2 Duty of Care 44.5.3 The Test of Negligence 44.5.4 Contributory Negligence 44.5.5 Remedy for Negligence Under the Indian Legal Systems 44.5.6 Legal Procedure and Evidentiary Requirements 44.6 Conclusion Annexures A.1 AOMSI—Informed Consent Forms for All Procedures https://www.aomsi.com/WebPages/downloads.aspx A.2 Quantification of Disability A.2.1 Quantification of Dento-facial Disability/Deformity: A Proposal [19] Review of Quantification Criteria Definitions Recommended Quantification for the Dento-facial Region Areas of Deformity Evaluation—Hard Tissues: Areas of Deformity Evaluation—Soft Tissue Discussion A.2.1.2 Duties of Witness References 45: Research and Publishing in Oral and Maxillofacial Surgery 45.1 Introduction 45.2 The Science of Research 45.3 The Scientific Research Method (Table 45.1) 45.3.1 Observation 45.3.2 Literature Review 45.3.3 Purpose of Research 45.3.4 Hypothesis 45.3.5 Define the Variables 45.3.6 Data Collection 45.3.7 Data Analysis 45.3.8 Data Interpretation 45.3.9 Test or Revision of Hypothesis 45.3.10 Conclusions and Recommendations 45.3.11 Reporting/Communicating/Publishing Findings 45.4 Constraints in Surgical Research 45.4.1 Ethics 45.4.2 Funding 45.4.3 Confirmation Bias 45.4.4 Cognitive Dissonance 45.5 Publishing 45.5.1 Electronic Media 45.5.2 Magazines 45.5.3 Textbooks 45.5.4 Peer-Reviewed Journals 45.6 Conclusion Further Reading Part XV: Salivary Gland Pathologies 46: Salivary Gland Pathologies 46.1 Introduction 46.2 Surgical Anatomy 46.2.1 Parotid Gland 46.2.1.1 Identification of the Facial Nerve [5, 6] 46.2.1.2 Facial Nerve Monitoring 46.2.2 Submandibular Glands 46.2.3 Sublingual Glands 46.3 Diagnosis and Diagnostic Aids 46.4 Non-neoplastic Diseases (Table 46.5) 46.4.1 Acute Bacterial Sialadenitis 46.4.1.1 Clinical Features 46.4.1.2 Management 46.4.2 Chronic Bacterial Sialadenitis [18] 46.4.2.1 Management 46.4.3 Obstructive Disorders (Video 46.1) 46.4.3.1 Etiology 46.4.3.2 Diagnosis and Management 46.5 Viral Infections of Salivary Glands 46.5.1 Mumps 46.5.1.1 Pathogenesis 46.5.1.2 Clinical Features 46.5.1.3 Treatment 46.5.1.4 Complications 46.5.2 HIV Parotitis 46.5.2.1 Management 46.6 Noninfectious Inflammatory Diseases 46.6.1 Mikulicz’ Disease 46.6.1.1 Clinical Features [28] 46.6.1.2 Management 46.6.2 Sjögren’s Syndrome 46.6.2.1 Management 46.6.3 Mucoceles (Video 46.2) 46.6.3.1 Clinical Features 46.6.3.2 Management 46.6.4 Ranula 46.6.4.1 Management 46.7 Salivary Gland Tumors 46.7.1 Etiology 46.7.2 Incidence 46.7.3 TNM Staging of Salivary Gland Tumors According to American Joint Commission on Cancer (AJCC) 2002 [42] 46.7.4 Classification of Salivary Gland Tumors 46.7.5 Pleomorphic Adenoma 46.7.5.1 Clinical Features 46.7.5.2 Histopathology [48] 46.7.5.3 Management 46.7.6 Monomorphic Adenoma 46.7.7 Warthin’s Tumor 46.7.7.1 Clinical Features 46.7.7.2 Management 46.7.8 Oncocytoma 46.7.8.1 Clinical Features 46.7.8.2 Management 46.7.9 Basal Cell Adenoma 46.7.9.1 Clinical Features 46.7.9.2 Management 46.7.10 Canalicular Adenoma 46.7.10.1 Clinical Features 46.7.10.2 Management 46.7.11 Sialadenoma Papilleferum 46.7.11.1 Clinical Features 46.7.11.2 Management 46.7.12 Inverted Ductal Papilloma 46.7.12.1 Clinical Features [56] 46.7.12.2 Treatment and Prognosis 46.7.13 Intraductal Papilloma 46.7.13.1 Treatment and Prognosis 46.7.14 Mucoepidermoid Carcinoma 46.7.14.1 Clinical Features 46.7.14.2 Management 46.7.15 Adenoid Cystic Carcinoma 46.7.15.1 Clinical Features 46.7.15.2 Management of Adenoid Cystic Carcinoma 46.7.16 Clear Cell Carcinoma 46.7.16.1 Clinical Features 46.7.16.2 Management 46.7.17 Epithelial-Myoepithelial Carcinoma 46.7.17.1 Clinical Features 46.7.17.2 Management 46.7.18 Carcinosarcoma 46.7.18.1 Clinical Features 46.7.18.2 Management 46.7.19 Undifferentiated Carcinomas 46.7.20 Squamous Cell Carcinoma 46.7.20.1 Clinical Features 46.7.20.2 Management 46.8 Surgical Management of Parotid Tumors (Video 46.3) 46.8.1 Skin Incisions for Parotidectomy [69] 46.8.2 Identification of the Facial Nerve 46.8.3 Surgical Management 46.8.3.1 Local Excision of Parotid Gland 46.8.3.2 Parotidectomy with Preservation of the Facial Nerve [75] 46.8.3.3 Functional Superficial Parotidectomy [76] 46.8.3.4 Partial Superficial Parotidectomy 46.8.3.5 Intraoral Deep Lobe Tumor Excision [79] 46.8.3.6 Total Parotidectomy with or Without Facial Nerve Preservation 46.8.3.7 Parotidectomy Using SMAS Plane for Dissection [73] 46.8.3.8 Parotidomandibulectomy and Temporoparotidectomy [80] 46.8.4 Parotidectomy in Continuity with Neck Dissection 46.8.5 Complications of Parotid Surgery 46.9 Surgical Management of Submandibular and Sublingual Gland Tumors 46.9.1 Incision 46.9.2 Extracapsular Excision of the Submandibular Salivary Gland [82] 46.10 Management of Minor Salivary Gland Tumors 46.10.1 Excision of Palatal Pleomorphic Adenomas [83] 46.10.2 Excision of Palatal Mucoepidermoid Carcinoma [83] 46.10.3 Excision of Palatal Adenoid Cystic Carcinoma [83] 46.10.4 Excision of Neoplasms of the Cheek and Lips 46.10.5 Complications 46.11 Recent Advances [84] 46.12 Conclusion References Additional Reading 47: Obstructive Salivary Gland Disease and Sialendoscopy 47.1 Introduction 47.2 Obstructive Salivary Diseases 47.3 Sialendoscopy 47.4 Evolution of Sialendoscopy 47.5 Indications and Contraindications 47.6 Investigations 47.7 Armamentarium 47.8 Anaesthesia and Technique 47.8.1 Positioning 47.8.2 Identification, Cannulation and Dilatation of Punctum 47.8.3 Sialendoscopic Evaluation 47.9 Diagnostic vs. Interventional Sialendoscopy 47.10 Complications 47.11 Summary References Part XVI: Maxillofacial Traumatology 48: Primary Assessment and Care in Maxillofacial Trauma 48.1 Introduction [1, 2] 48.2 Triage [4] 48.2.1 Glasgow Coma Scale (Please Refer Table 7.5 in Chap. 7 of this book) 48.3 Primary Survey and Resuscitation [6] 48.3.1 Airway with Cervical Spine Control 48.3.2 Airway and Ventilatory Problems in Maxillofacial Trauma (Please Refer Chap. 7 of this book) 48.3.3 Airway and Ventilation Are the First Priorities 48.3.4 Objective Signs of Airway Obstruction 48.3.5 Airway Management [7, 8] 48.3.6 Breathing with Ventilation 48.3.7 Ventilation 48.3.8 Objective Signs of Inadequate Ventilation 48.3.9 Circulation and Hemorrhage Control 48.3.10 Bleeding 48.3.11 Disability Management 48.3.12 Exposure with Environment Control 48.3.13 Monitoring of Adequacy of Oxygenation 48.3.14 Electrocardiographic (ECG) Monitoring 48.3.15 Fluid Resuscitation 48.3.16 Urinary and Gastric Catheters 48.4 Secondary Survey [10–12] 48.4.1 History Taking 48.4.2 Physical Examination 48.4.3 Four-Person Logroll 48.4.4 Head 48.4.4.1 Classification of Brain Injury 48.4.5 Maxillofacial Structures 48.4.6 Cervical Spine and Neck 48.4.7 Chest 48.4.7.1 Classification of Chest Trauma 48.4.7.2 Managing Chest Trauma [15] 48.4.7.3 Airway 48.4.7.4 Breathing 48.4.7.5 Tension Pneumothorax 48.4.7.6 Open Pneumothorax (Sucking Chest Wound) 48.4.7.7 Flail Chest and Pulmonary Contusion 48.4.7.8 Massive Hemothorax 48.4.7.9 Cardiac Tamponade 48.4.8 Abdomen [20] 48.4.8.1 Focused Assessment Sonography in Trauma (FAST) [22] 48.4.9 Perineum/Rectum/Vagina 48.4.10 Musculoskeletal System 48.5 Conclusion References 49: Management of Soft Tissue Injuries in the Maxillofacial Region 49.1 Introduction 49.2 Etiology 49.3 Classification of Soft Tissue Injuries 49.3.1 Common Soft Tissue Injuries 49.4 Initial Evaluation and Assessment 49.5 History and Examination 49.6 Management of Soft Tissue Injuries 49.7 Wound Dressings 49.8 Other Therapies 49.9 Necrotizing Fasciitis 49.10 Principles of Soft Tissue Healing 49.11 Types of Wound Healing 49.12 Complications in Wound Healing 49.12.1 Prevention of Hypertrophic or Keloid Scars 49.13 Recent Advances in Soft Tissue Management 49.14 Conclusion 49.15 Case Scenarios Case Scenario 1 Case Scenario 2 References 50: Dentoalveolar Injuries and Wiring Techniques 50.1 Definition 50.2 Incidence 50.3 Introduction 50.4 Diagnosis and Treatment Planning 50.5 Clinical Examination 50.5.1 Extra-oral 50.5.2 Intra-oral 50.5.3 Jaws and Alveolar Bone 50.5.4 Percussion and Pulp Testing 50.6 Radiographic Examination 50.6.1 Storage and Transportation Media 50.7 Treatment at the Clinic 50.7.1 Delayed Replantation (more than 60 min) 50.7.2 Stabilization 50.7.3 Technique 50.7.3.1 Wire Acid Etch Composite Splint 50.7.4 Complications 50.8 Alveolar Process Fracture 50.9 Management of Dentoalveolar Fracture 50.9.1 Treatment Options 50.9.2 Specific Treatment Options 50.9.3 Wiring Techniques 50.9.4 Armamentarium and Principles (Fig. 50.10) 50.9.5 Principles 50.9.6 Technique 50.9.6.1 Bridle Wire [26, 27] Technique 50.9.6.2 Gilmer’s Direct Interdental Wiring [26, 27] Technique 50.9.6.3 Interdental Eyelet Wiring (Ivy Loop Method) [26, 27] (Video 50.1) Technique Modifications Technique of Clove Hitch 50.9.6.4 Continuous or Multiple Loop Wiring [26, 27] Technique Modification 50.9.6.5 Risdon’s Wiring [26, 27] Indications Technique 50.9.6.6 Obwegeser Wiring [26, 27] Technique 50.9.6.7 Arch Bar [26, 27] (Video 50.2) Indications Technique Advantages Disadvantages Complications 50.10 Maxillomandibular Fixation (MMF) Screws [28] (Video 50.3) 50.10.1 Introduction 50.10.2 First Generation 50.10.3 Second Generation 50.10.4 Advantages 50.10.5 Disadvantages 50.11 Conclusion References 51: Principles of Internal Fixation in Maxillofacial Surgery 51.1 Introduction 51.1.1 Association of Osteosynthesis (AO Principles) 51.2 History 51.2.1 Evolution of Fixation Methods 51.3 Concept of Bone Healing 51.3.1 Secondary Bone Healing (Fig. 51.1) 51.3.1.1 Stage I: Inflammation Induction 51.3.1.2 Stage II: Fibrocartilaginous (Soft) Callus Formation 51.3.1.3 Stage III: Hard Callus Formation 51.3.1.4 Stage IV: Remodeling 51.3.2 Primary Bone Healing (Contact and Gap Healing) 51.4 Biomechanics of Facial Skeleton [5] 51.4.1 Mandible Fractures 51.4.2 Midface Fractures 51.5 Functions of Plates 51.5.1 Compression 51.5.2 Neutralization 51.5.3 Tension Band 51.6 Fixation Methods and Devices [6] (Table 51.3) 51.6.1 Material 51.6.2 Rigid Fixation 51.6.2.1 Rigid Internal Fixation (RIF) 51.6.2.2 Examples of RIF 51.6.3 Nonrigid Internal Fixation 51.6.4 Semirigid Fixation 51.6.5 Load-Bearing Versus Load-Sharing Fixation (Table 51.4) 51.7 Classification of Plating System [8] 51.7.1 Locking Plate-Screw Systems 51.7.2 Reconstruction Plates 51.7.3 Lag Screw Fixation 51.7.3.1 The Principle of Lag Screw 51.7.3.2 Absolute Rigid Fixation Provided by Lag Screw 51.7.4 Comparison of Lag Screw Fixation Methods with Different Methods of Fixations [17–19] 51.7.5 Champy’s System [21] 51.7.5.1 Materials 51.7.5.2 Miniplates (Fig. 51.11) 51.7.5.3 Screw 51.7.5.4 Biomechanical Properties of Screw (Fig. 51.12) [22] 51.7.5.5 Self-Tapping and Drilling Screws [23, 24, 25] 51.7.5.6 Monocortical vs. Bicortical Screws 51.7.6 Microplates 51.7.6.1 Micromesh 51.7.7 AO/ASIF System [27] 51.7.7.1 Plates 51.7.7.2 Dynamic Compression Plate (DCP) 51.7.7.3 Eccentric Dynamic Compression Plate (EDCP) [27] 51.7.8 Bioresorbable Fixation Systems 51.8 Recent Developments 51.8.1 Three-Dimensional (3D) Plates (Fig. 51.13) 51.8.2 Virtual Surgical Planning, Computer-Assisted Design, and 3D Modelling 51.8.3 Intraoperative Imaging [29] 51.9 Conclusion References 52: Fractures of the Mandible 52.1 Definition 52.2 Introduction 52.3 Surgical Anatomy 52.3.1 Angle of the Mandible 52.3.2 Canine Region of the Mandible 52.3.3 Symphysis and Parasymphysis of Mandible 52.4 Classification 52.4.1 Classification of Mandibular Fracture According to Site (Fig. 52.1) 52.4.2 Classification of Mandibular Fracture According to the Impact 52.4.3 Combination of Fracture 52.4.4 Classification of Mandibular Fracture According to Displacement 52.5 Clinical Features 52.6 Clinical Examination 52.6.1 Bimanual Palpation 52.6.2 Compression Test 52.7 Radiographic Examination 52.7.1 Are Postoperative Radiographs Necessary? 52.8 Emergency Management (refer Chap. 48 of this book) 52.9 Goals of Treatment of Mandibular Fracture (Table 52.5) 52.10 Treatment Options for Different Sites 52.10.1 Closed Reduction (Table 52.6) 52.10.2 Clinical Tip 52.10.3 Open Reduction (Table 52.7) 52.10.4 Steps in Open Reduction Internal Fixation (ORIF) of Mandible Fracture 52.10.5 Symphysis and Parasymphysis Fracture (Video 52.1) 52.10.6 Parasymphysis Fracture 52.10.7 Mandibular Angle 52.10.7.1 Impact of Presence or Absence of Impacted Mandibular Third Molar (IM3M) on Angle and Condylar Fracture 52.10.7.2 Open vs. Closed Reduction 52.10.7.3 Approaches for ORIF 52.10.7.4 Advantages of Transbuccal Approach [16] 52.10.7.5 Single vs. Two Plates vs. 3D Plates 52.10.7.6 Extraction vs. Retention of IM3M in Angle Fracture 52.10.8 Body Fracture 52.10.9 Ramus Fracture 52.10.9.1 Management of Triangular Fragments (TF) at the Lower Border 52.10.10 Coronoid Fracture 52.10.10.1 Indications for Conservative or Open Reduction of Coronoid Fractures (Table 52.9) 52.10.11 Bilateral Fracture of Mandible 52.10.12 Comminuted Mandible Fractures 52.11 Inferior Alveolar Nerve (IAN) Injury in Mandible Fracture 52.12 Geriatric Mandibular Fracture 52.12.1 Management 52.13 Pediatric Mandibular Fractures 52.13.1 Management 52.14 Use of Bone Grafts in Mandible Fracture Treatment 52.15 Postoperative Care 52.16 Complications of Mandible Fracture 52.16.1 Management of Mandibular Non-union Depending upon the Size of the Defect (Table 52.10) [61] 52.17 Recent Advances 52.18 Case Scenarios References 53: Fracture of the Mandibular Condyle 53.1 Introduction 53.2 Surgical Anatomy 53.2.1 Condyle 53.2.2 Articular Disc 53.2.3 Capsule and Ligaments 53.2.4 Muscles of Mastication 53.2.5 Vascularisation 53.2.6 Innervation 53.2.7 Facial Nerve 53.3 Biomechanics of Condylar Fracture 53.3.1 Mechanism of Injury 53.3.2 Effect of Condylar Fracture 53.3.3 Adaptation to Fracture 53.4 Classification of Condylar Process Fractures 53.5 Incidence and Pattern 53.6 Clinical Features 53.6.1 Condylar Fractures: Unilateral 53.6.2 Condylar Fractures: Bilateral 53.6.3 Radiographic Assessment 53.7 Management 53.7.1 Non-operative 53.7.2 Closed Reduction 53.7.3 Open Reduction and Fixation 53.7.3.1 Submandibular/Periangular (Fig. 53.15a, b) (Video 53.1) 53.7.3.2 Retromandibular (Fig. 53.16a, b) (Video 53.3) Transparotid Approach Retroparotid Approach 53.7.3.3 Preauricular Approach (Fig. 53.17a, b) (Video 53.4) 53.7.3.4 Retroauricular Approach 53.7.4 Reduction 53.7.5 Fixation Techniques (Fig. 53.20a–d), (Case 1: Fig. 53.21a–b), (Case 2: Fig. 53.22), (Case 3: Fig. 53.23a–e), (Case 4: Fig 53.24a–d) 53.8 Condylar Fractures in Children 53.9 Complications of Condylar Fractures (Case 5: Fig. 53.26) (Case 6: Fig. 53.27a–c) 53.10 Conclusion References 54: Intraoral Endoscopic Approach for Treatment of Condylar Fractures of the Mandible 54.1 Introduction 54.2 Surgical Technique 54.2.1 Special Surgical Instruments and Devices 54.2.2 Surgical Access 54.2.3 Surgical Procedure 54.2.4 Osteosynthesis Material 54.3 Complications 54.4 Conclusion 54.5 Case Scenario References 55: Maxillary Fractures 55.1 Introduction 55.1.1 History (Table 55.1) 55.1.2 Surgical Anatomy/Osteology 55.1.3 Applied Anatomy of the Midfacial Bones 55.1.3.1 Maxilla 55.1.3.2 Vascular Supply and Innervation 55.2 Classification 55.2.1 René Le Fort1901 [2] 55.2.1.1 Le Fort I Low Level Fracture/Guerin Fracture 55.2.1.2 Le Fort II Pyramidal or Sub-zygomatic Fracture 55.2.1.3 Le Fort III Transverse or Supra-zygomatic Fracture 55.2.2 Killey’s Classification (1965) [2] (Table 55.2) 55.2.3 Rowe and Williams’s Classification (1985) [2] (Table 55.3) 55.2.4 Marciani (1993: Modification of Le Fort Fractures) [1] 55.2.5 Palatal Fractures Classification: Hendrickson’s Classification (1998) [7] (Figs. 55.7, 55.8, and 55.9; Table 55.5) 55.3 Clinical Features (Box 55.1) 55.3.1 Le Fort I Fractures 55.3.2 Le Fort II Fractures 55.3.3 Le Fort III Fractures (Also see Fig. 49.5) 55.3.4 Unusual Fracture Patterns 55.4 Radiographic Examination 55.4.1 CT Scans 55.5 Treatment of Maxillary fractures 55.5.1 General Considerations in Treatment of Maxillary Fractures 55.5.2 Suspension Wiring 55.5.3 Rigid Internal Fixation 55.5.4 Approaches to the Maxilla 55.5.4.1 Maxillary Vestibular Approach 55.5.5 Fixation of Le Fort I # 55.5.6 Fixation of Le Fort II Fractures 55.5.7 Fixation of Le Fort III Fractures 55.6 Complications of Le Fort Fractures (Table 55.6) 55.7 Palatal Fractures 55.7.1 Surgical Splints 55.8 Special Considerations 55.8.1 Maxillary Fractures in Geriatric Patients 55.8.2 Maxillary Fractures in Children 55.8.3 Haemorrhage Control in Maxillary Fractures 55.9 Recent Advances 55.10 Conclusion 55.11 Case Scenario - A case of maxillary Lefort I fracture where bone grafting was done (Fig. 55.26a–g) References 56: Fractures of the Zygomaticomaxillary Complex 56.1 Introduction 56.2 Surgical Anatomy 56.2.1 Articulations 56.2.2 Relations 56.2.3 Muscle and Fascia Attachments 56.2.4 Zygomatic Arch 56.2.5 Nerves and Blood Vessels 56.3 Classification 56.3.1 Classification of ZMC Fractures 56.3.2 Classification of Arch Fractures 56.4 Clinical Assessment 56.4.1 Examination of the Eye 56.4.2 Examination of the Face 56.5 Imaging for ZMC Fractures 56.6 Principles of Management 56.6.1 Indications and Contraindications for Intervention [5, 37] 56.6.2 Timing of Intervention [39] 56.6.3 Surgical Objectives 56.6.4 Need for Prophylactic Antibiotics 56.7 Preoperative Planning [42] 56.7.1 CT Evaluation 56.7.2 Model Surgery 56.7.3 Soft Tissue Analysis 56.8 Reduction of ZMC Fractures 56.8.1 Direct vs. Indirect Method 56.8.2 Extraoral Techniques 56.8.3 Intraoral Techniques 56.8.4 Reduction of Zygomatic Arch 56.8.5 Intra-operative Assessment of Reduction 56.8.6 Precautions During and After Reduction 56.9 Fixation and Stabilization of ZMC Fractures 56.9.1 Need for Fixation 56.9.2 Fixation Principles 56.9.3 Surgical Access to Fixation 56.9.3.1 Supraorbital/Lateral Brow Incision (Fig. 56.38) 56.9.3.2 Upper Eyelid Blepharoplasty Incision (Fig. 56.38) 56.9.3.3 Subciliary Incision [71, 72] (Figs. 56.38, 56.44a and 56.45a, b) 56.9.3.4 Extended Lateral Exposure with the Subciliary Approach Fig. 56.46 [70] 56.9.3.5 Subtarsal Approach [73] (Figs. 56.38, 56.44c and 56.47) 56.9.3.6 Infra-orbital Incision (Figs. 56.38 and 56.44d) 56.9.3.7 Transconjunctival Incision [78, 79] (Figs. 56.38 and 56.49) 56.9.3.8 Vestibular [85] Incision (Figs. 56.50 and 55.16) 56.9.3.9 Preauricular [86] (Figs. 56.38, 56.51, 53.17a, b and 65.6) (Refer Video on pre auricular approach in Chap. 53) 56.9.3.10 Coronal Incision [88] (Figs. 56.38, 56.52a, b and 85.1) 56.9.4 Fixation Methods 56.9.5 Fixation of Zygomatic Arch 56.10 Soft Tissue Resuspension [101, 102] 56.11 Postoperative Care 56.12 Pediatric Considerations 56.12.1 Nonsurgical vs. Surgical Intervention [109] 56.12.2 Approaches and Fixation Principles 56.12.3 Osteosynthesis Methods 56.13 Malunited ZMC Fractures [114] 56.14 Bilateral ZMC Fractures 56.15 Complications of ZMC Fractures [3–5] 56.16 Recent Trends 56.17 Conclusion 56.18 Case Scenarios Case Scenario 1: Fracture of right ZMC (Fig. 56.64) Patient: 21-Year-Old Male, with History of RTA Case Scenario 2: Fracture of left ZMC and orbital floor (Fig. 56.65 a–h) Patient: 27-Year-Old Male with History of RTA and delayed presentation after 2 months References 57: Orbital Fractures 57.1 Introduction 57.2 Surgical Anatomy of the Orbit 57.2.1 Orbital Walls 57.2.2 Muscles of the Orbit (Fig. 57.6a) 57.2.3 Movements of the Eye and Their Innervation 57.2.4 Orbital Septum and Tarsal Plates (Fig. 57.7) 57.2.5 Conjunctiva 57.2.6 Fascial Sheath of the Eyeball (Fig. 57.6c) 57.2.7 Orbital Fat 57.3 Classification System 57.4 Blowout and Blow-In Fractures 57.5 Biomechanics of Injury 57.6 Initial Assessment 57.6.1 Ophthalmologic Examination 57.6.2 Clinical Features 57.6.2.1 Enophthalmos/Hypophthalmos (Fig. 57.15a, b) 57.6.2.2 Retrobulbar Hemorrhage (Fig. 57.16) 57.6.2.3 Lacrimal System Injuries 57.6.2.4 Oculocardiac Reflex (Trigeminocardiac Reflex) 57.6.2.5 Superior Orbital Fissure Syndrome (Box 57.5) 57.6.2.6 Orbital Apex Syndrome (Fig. 57.18) (Box 57.5) 57.6.2.7 Traumatic Optic Neuropathy (TON) (Box 57.5) 57.6.3 Investigations 57.7 Approaches to the Orbit 57.7.1 Transcutaneous Approaches 57.7.1.1 Lynch 57.7.1.2 Extended Glabellar Approach (Fig. 57.23) 57.7.2 Trans-caruncular Approach 57.7.3 Transconjunctival Approach (Fig. 57.25) 57.7.4 Trans-antral Endoscopic-Assisted Approach (Fig. 57.27a, b) 57.7.5 Coronal Approach 57.8 A Clinical Sequence for Treatment Planning and Management of Orbital Fractures 57.8.1 Type I (Orbito-Zygomatic) 57.8.2 Type II (Internal Orbital) 57.8.2.1 Fractures of the Orbital Roof 57.8.2.2 Fractures of the Lateral Orbital Wall 57.8.2.3 Medial Wall Fractures 57.8.2.4 Orbital Floor Fractures Which Fractures of the Orbital Floor Need Intervention? When Is the Right Time to Intervene? What to Use for Reconstruction of the Orbital Defect? Guidelines for Deep Orbital Dissection De-herniation of the Orbital Contents and Locating the Posterior Ledge 57.8.3 Type III (Naso-Orbito-Ethmoid Type) (Refer Chap. 58) 57.8.4 Type IV (Complex Fractures of the Face with Orbital Fractures) 57.9 Management of Orbital Emergencies 57.10 Pediatric Considerations (Figs. 57.52a–d and 57.53a, b) 57.11 Secondary Correction of Orbital Deformities 57.12 Complications 57.12.1 Immediate Complications 57.12.2 Delayed Complications 57.13 Recent Advances in Management of Orbital Fractures 57.13.1 Navigation and CAS for Orbital Fractures and Reconstruction 57.13.2 Patient-Specific Implants (Fig. 57.56a–c) 57.14 Conclusion 57.15 Case Scenarios References Additional Reading 58: Frontal and Naso-Orbito-Ethmoid Complex Fractures 58.1 Introduction 58.2 Applied Surgical Anatomy 58.3 Historical Perspective and Classification [6] 58.3.1 Classification 58.3.2 Paediatric NOE Fractures (Fig. 58.2) Classification: Burstein et al.’s [9] (Box 58.2) 58.4 Aetiology, Clinical Features and Diagnosis 58.5 Management 58.5.1 Surgical Access for NOE 58.5.2 Trans Nasal Canthopexy 58.5.3 Soft Tissue Readaptation 58.5.4 Post-operative Evaluation [20] 58.6 Complications 58.7 Frontal Sinus Fracture 58.7.1 Introduction 58.7.2 Applied Anatomy of Frontal Sinus 58.7.3 Functions of Frontal Sinus 58.7.4 Clinical Features [29] 58.7.5 Radiographic Features 58.7.6 Classifications 58.7.7 Stanley’s Classification of Frontal Sinus Fracture [31] 58.7.8 Gonty Et al. Classification of Frontal Sinus Fracture [32] 58.7.9 Management (Box 58.6) [33] 58.7.10 Indications of Surgery in Frontal Sinus Fractures [35] 58.7.11 Management of Anterior Table Fracture [36–38] 58.7.12 Treatment of Posterior Table Fracture [41] 58.7.13 Methods of Treatment of Damaged Frontonasal Duct [42] 58.7.13.1 Material Used for Sinus Obliteration [43] 58.7.14 Cranialization [44, 45] 58.7.15 Key Points 58.8 Conclusion References 59: Gunshot Injuries of the Maxillofacial Region 59.1 Introduction 59.2 Pathologic Anatomy and Classification 59.3 Initial Evaluation, Triage, and Damage Control Surgery 59.4 Diagnostic Imaging 59.5 Definitive Management of Facial Gunshot Wounds 59.6 Debridement 59.7 Infection and Role of Antibiotics 59.8 Soft Tissue Reconstruction 59.9 Fracture Stabilization and Hard Tissue Reconstruction 59.10 Timing of Definitive Reconstruction 59.11 Recent Advances 59.12 Conclusion References 60: Panfacial Fractures 60.1 Introduction 60.2 Epidemiology 60.3 Management Philosophy 60.3.1 History of Management 60.3.2 Indications 60.3.3 Contraindications 60.3.4 Clinical Findings 60.4 Workup 60.5 Emergency Treatment 60.5.1 Airway Compromise 60.5.2 Severe Haemorrhage 60.5.3 Large Open Wounds 60.5.4 Surgery for Associated Life-Threatening Injuries 60.5.5 Definitive Treatment 60.6 Preoperative Documentation and Planning 60.7 Intra-operative Details 60.7.1 Buttresses of the Facial Skeleton 60.7.2 Key Contributors to Facial Architecture 60.7.3 Various Approaches to Facial Skeleton 60.8 Sequencing Options 60.8.1 Bottom to Top Approach 60.8.2 Top to Bottom Approach 60.8.3 Essentials in Either Approach 60.9 Paediatric Panfacial Fractures 60.10 Complications 60.11 Tips and Tricks 60.12 Case Scenario Case 1: (Figs. 60.13a–d, 60.14a–f, and 60.15a–c) Shows Management of a Case of Pan Facial Fracture Case 2 (Figs. 60.16a–d, 60.17a–e, and 60.18a–d) 60.13 Conclusion References Additional Reading 61: Residual Deformities of the Maxillofacial Region 61.1 Introduction 61.1.1 Preventive Wound Management [4] 61.1.2 Volume Issues in Deformities [3] 61.1.2.1 Minor Loss of Tissue [3] 61.1.2.2 Major Loss of Tissue [3] 61.1.3 Tissue Expanders [4–6] 61.1.3.1 Properties of Tissue Expanders [4, 5, 7–9] 61.1.3.2 Biomechanical Properties 61.1.3.3 Technique 61.2 Grafts in Residual Deformity 61.2.1 Ideal Characteristics of Bone Graft Material [11] 61.2.2 Biology of Bone Grafting 61.2.2.1 Types and Tissue Sources for Grafting (Table 61.2 and Chart 61.3) 61.2.3 Bone Grafts in Hard Tissue Residual Deformities 61.2.3.1 Nasal Deformities [19] 61.2.3.2 Orbital Deformities [19] 61.2.4 Alloplastic Materials [19–24] 61.2.5 Use of Grafts in Associated Residual Structural Damages 61.3 Hard Tissue Deformities 61.3.1 Patient Assessment 61.3.2 Residual Mandibular Deformities [3, 45–50] 61.3.2.1 Deformity in the Ascending Ramus of the Mandible 61.3.2.2 Surgical Options for Post-traumatic Residual Deformities 61.3.2.3 Non-union [45–50] 61.3.2.4 Malunion/Malocclusion: [46, 51, 52] 61.3.2.5 Early Malunions 61.3.2.6 Late Malunions 61.3.2.7 Malunions/Malocclusion and Condylar Fractures [53–56] 61.3.2.8 Facial Asymmetry [46] 61.3.2.9 Principles of Mandibular Reconstruction [45, 57] 61.3.3 Midface Deformities [3, 58] 61.3.4 Residual Maxillary Deformities [3, 58] 61.3.4.1 Immediate Repositioning of Maxilla and Midface Complex 61.3.4.2 Old Le Fort I and II Fractures [3] 61.3.4.3 Displaced Edentulous Maxilla [3] 61.3.4.4 Old Le Fort III Fractures (Figs. 61.10 and 61.11) 61.3.5 Post-traumatic Hypertelorism [3, 44, 65–71] 61.3.6 Residual Zygomatic Deformities [3, 58] 61.3.6.1 Associated Defects of the Orbital Zone [3] 61.3.7 Secondary Orbital Reconstruction [5, 72, 73] 61.3.8 Nasal Deformities [3, 75] 61.3.8.1 Potential Complications Associated with Nasal Deformities [3] (Chart 61.9) 61.3.8.2 Deformities of the Nasal Bridge or Nasomaxillary Region [3] 61.3.8.3 Depression of Nose [3] (Saddle-Shaped Deformity) 61.3.8.4 Depression of Lower Half of Nasal Crest [3] 61.3.8.5 Naso-Orbital Deformities [3] 61.3.8.6 Surgical Management 61.3.8.7 Nasofrontal Deformities [3] Essentials in Surgical Management: 61.3.8.8 Naso-Fronto-Ethmoidal Deformities [3] Essentials in Management of Naso-Fronto-Ethmoidal Deformities: 61.3.8.9 Delayed Management of Orbital Hypertelorism and Naso-Orbito-Ethmoidal (NOE) Fractures [73, 75–77] 61.3.8.10 Secondary or Delayed Management of Orbital Hypertelorism Associated with NOE Complex Fractures [75–77] 61.3.8.11 Conclusion 61.4 Post-oncological Deformities 61.4.1 Lip Deformities [79–83] 61.4.2 Management of Intra-oral Defects Involving Floor of the Mouth and Alveolar Ridge Tumours 61.4.3 Management of Defects of Oropharynx 61.4.3.1 Management of Soft Palate Defects [88] 61.4.3.2 Management of Tongue Defects [89, 90] 61.4.3.3 Management of Posterior Pharyngeal Wall [90] 61.4.4 Deformities Associated with Intra-oral Disfigurement [91–98] 61.4.5 Deformities Associated with Healing Tissues [91, 92, 99, 100] 61.4.6 Functional Deformities Associated with Oro-Oncological Surgery 61.4.6.1 Spinal Accessory Nerve 61.4.6.2 Phrenic Nerve 61.4.6.3 Hypoglossal Nerve and lingual Nerve [92, 101, 104] 61.4.6.4 Vagus Nerve, Recurrent Laryngeal Nerve and Superior Laryngeal Nerve [91] 61.4.6.5 Sympathetic Trunk [92, 101, 104] 61.4.6.6 Marginal Mandibular Branch of Facial Nerve [92, 105] 61.5 Recent Advances 61.5.1 Endoscopy in Residual Deformitites [106, 107] 61.6 Conclusion References Introduction Grafts in Residual Deformities Hard Tissue Deformities Post Oncological Deformities Recent Advances: Endoscopy in Management of Residual Deformities Part XVII: Temporomandibular Joint Disorders 62: Myofascial Pain Dysfunction Syndrome 62.1 Introduction 62.2 Definitions 62.2.1 Evolving Terminologies 62.2.2 Current Definition 62.3 Etiopathogenesis and Proposed Mechanisms 62.4 Patient History and Clinical Characteristics 62.5 Examination 62.5.1 Imaging Techniques 62.6 Psychological Assessment 62.7 Pathophysiology of TMJ Pain 62.8 Role of Parafunctional Habits 62.8.1 Bruxism 62.9 Clinical Signs of MPDS 62.9.1 Clinical Test 62.10 Principles of Management 62.10.1 Role of Evidence-Based Management 62.10.2 Formulating a Comprehensive Problem List 62.10.3 Role of Interdisciplinary Management for the Complex Patient 62.10.4 The Role of Occlusal Splint: Termination of the Cycle of Habitual Pain 62.10.5 Occlusal Adjustments 62.11 Modalities of Management of MPDS 62.11.1 Muscle Exercises 62.11.2 Muscle Treatments 62.11.3 Trigger Point (TrP) Injections 62.11.4 Trigger Points 62.11.5 Bite Adjustment 62.12 Intraoral Appliance Therapy (Refer to suggested reading at the end of the chapter) 62.12.1 Pharmacotherapy 62.12.1.1 Non-steroidal Anti-inflammatory Drugs (NSAIDs) 62.12.1.2 Opioids and Narcotic Analgesics 62.12.1.3 Antidepressants 62.12.1.4 Muscle Relaxants 62.12.2 Supportive Therapy 62.12.2.1 Ultrasound and Electrogalvanic Stimulation 62.13 Treatment Summary 62.14 Recent Advances 62.14.1 Botulinum Toxin Injections 62.14.2 Cold and Soft Lasers 62.15 Summary and Conclusion 62.16 Case Scenarios References Suggested reading 63: Internal Derangements of the Temporomandibular Joint 63.1 Introduction 63.2 Epidemiology 63.3 Etiology 63.4 Anatomy and Function Relevant to Internal Derangement 63.5 Clinical Features and Diagnosis 63.5.1 Patient History 63.5.2 Patient Examination (Fig. 63.6a–c) 63.5.3 Radiographic Evaluation 63.5.4 Serology 63.5.5 Diagnostic Local Anesthetic Block 63.6 Treatment of Internal Derangement 63.6.1 Nonsurgical Treatment 63.6.2 Surgical Treatment (Fig. 63.10) 63.6.3 Arthrocentesis 63.6.4 Arthroscopy 63.6.4.1 Viscosupplementation with Hyaluronic Acid 63.6.4.2 Platelet-Rich Plasma 63.6.4.3 Open Joint Surgery and Arthroplasty 63.7 Conclusion References 64: Temporomandibular Joint Dislocation 64.1 Introduction 64.2 Classification (Box 64.2) 64.3 Etiopathogenesis (Table 64.1) 64.4 Clinical Features (Mentioned in Box 64.3; Figs. 64.2a, b, 64.3, 64.4a, b, and 64.5a, b) 64.5 Investigations 64.6 Management of Dislocation (Box 64.4) 64.6.1 Acute Dislocation 64.6.1.1 Hippocratic/Nelaton’s Technique (Fig. 64.7) 64.6.1.2 Gag Reflex [3] 64.6.1.3 Wrist Pivot Method [7] (Fig. 64.8) 64.6.1.4 Extraoral Method [8] (Fig. 64.9a, b) 64.6.2 Management of Chronic Recurrent Dislocation/Subluxation (Box 64.5 and 64.6) 64.6.2.1 Conservative Methods Kinesio Taping (Fig. 64.11) 64.6.2.2 Minimally Invasive Treatment Injection of Sclerosing Solutions [9] Autologous Blood Injection [1] Injection of Platelet Rich Plasma (PRP) (Refer suggested reading at the end of the chapter) Prolotherapy [1] Injection of Botulinum Toxin [1] Extraoral Technique Intraoral Technique Arthroscopy [1] (Refer Chap. 63 on Internal Derangements of TMJ) Arthroscopic Capsulorrhaphy Arthroscopic Eminectomy 64.6.2.3 Surgical Treatment Capsular Tightening Procedure Capsulorrhaphy (Fig. 64.13a, b) Creation of Mechanical Obstacle Dautrey’s Procedure [10] (Fig. 64.14a, b) Glenotemporal Osteotomy (Fig. 64.16a, b and c) Modifications of Norman’s Procedure Removal of Mechanical Obstacle Eminectomy (Fig. 64.17a, b) Condylotomy and Condylectomy (Fig. 64.18a, b) Creating New Muscular Balance Pterygoid Dysjunction 64.6.3 Chronic Protracted Dislocation (Box 64.7) 64.7 Recent Advances 64.7.1 Raja’s Coronoid Repositioning Technique [17] 64.7.2 Wolford’s Anchoring Technique [18] (Fig. 63.15) 64.8 Case Scenarios Case 1 (Fig. 64.20a–d) Case 2 (Fig. 64.21a–d) References Suggested Reading 65: Temporomandibular Joint Ankylosis 65.1 Introduction and Etiopathogenesis 65.2 Clinical Features (Fig. 65.2) 65.2.1 Importance of Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) 65.2.2 Radiographic Features of Bony Ankylosis (Fig. 65.3) 65.3 Classifications 65.4 Preoperative Assessment 65.4.1 Investigations 65.4.2 Airway Implications of TMJ Ankylosis 65.4.2.1 Assessment 65.4.2.2 Types of Intubation According to Clinical Situations 65.5 Surgical Anatomy [11] 65.5.1 Nerve Anatomy (Figs. 46.6 and 65.5) 65.5.1.1 Facial Nerve 65.5.1.2 Trigeminal Nerve 65.5.2 Vascular Anatomy (Fig. 65.5) 65.5.3 Incisions (Fig. 65.6) [5] 65.5.3.1 Dingman’s Preauricular Approach (Refer video on Pre auricular approach in Chap. 53 and Fig. 53.17) 65.5.3.2 Blair (1914) 65.5.3.3 Thoma (1945) 65.5.3.4 Al-Kayat and Bramley (1979) (refer video on Al Kayat Bramley approach in Chap. 53) 65.5.3.5 Popowich’s Modification of Al-Kayat and Bramley [5] 65.5.3.6 Endaural [10] 65.5.3.7 Coronal Extension of Preauricular Incision 65.5.3.8 Rhytidectomy [10] 65.5.3.9 Postauricular 65.6 Treatment Protocol 65.6.1 Surgical Options for Ankylosis Release (Fig. 65.7a–c) 65.6.1.1 Gap Arthroplasty 65.6.1.2 Esmarch’s Procedure 65.6.1.3 Lateral Arthroplasty (LAP) 65.6.2 Arthroplasty with Ramus-Condyle Unit (RCU) Reconstruction (Details Covered Under “Hard Tissue Interposition”) 65.7 Soft Tissue Interpositional Materials (Video 65.1) 65.7.1 Temporalis Myofascial Flap (Fig. 65.8d, e) 65.7.2 Dermal Fat Graft (Fig. 65.8a, b, c) 65.7.3 Buccal Fat Pad Graft (BFP) (Fig. 65.8f, g) 65.7.4 Amniotic Membrane 65.7.5 Auricular Cartilage 65.8 Hard Tissue Interpositional Materials (RCU Reconstruction) 65.8.1 Rationale for RCU Reconstruction 65.8.2 Options, Techniques, Advantages, and Disadvantages 65.8.2.1 Ankylotic Mass (Fig. 65.9a) 65.8.2.2 Coronoid Process Graft (Fig. 65.9b) 65.8.2.3 Costochondral Graft (CCG) (Fig. 65.9c) 65.8.2.4 Ramus Osteotomy Pedicled Grafts (Fig. 65.10a, b) 65.8.2.5 Transport Distraction Osteogenesis (Fig. 65.11a, b) (Refer Chap. 87) 65.8.2.6 Alloplastic Total TMJ Replacement (TJR) (Fig. 65.11c) 65.9 Facial Deformity Secondary to TMJ Ankylosis 65.9.1 Osteotomies (Fig. 65.12a–c) 65.9.1.1 Le Fort I Osteotomy (Refer Chap. 69) 65.9.1.2 Sagittal Split Osteotomy (SSO) (Refer Chap. 68) 65.9.1.3 Inverted L Ramus Osteotomy (ILRO) (Fig. 68.6) 65.9.1.4 Genioplasty (Figs. 68.29, 68.32 and 68.34) 65.9.1.5 Orthomorphic Osteotomy 65.9.2 Distraction Osteogenesis (DO) 65.9.2.1 Simultaneous Maxillomandibular DO 65.9.2.2 Orthomorphic DO (Figs. 65.13a–d, 78.23, 78.24 and 78.25) 65.9.2.3 Genial Distraction 65.9.2.4 Unidirectional DO (Fig. 65.14a–i) 65.9.2.5 Bidirectional DO (Fig. 65.15a–g) 65.9.2.6 Impact of Mandibular DO on OSA 65.10 Sequence of Release and Deformity Correction 65.10.1 Multistage Surgical Treatment 65.10.1.1 Multistage with Ankylosis Release First 65.10.1.2 Multistage with Distraction First 65.10.2 Single-Stage Surgical Treatment 65.10.2.1 Single-Stage Release with Orthognathic Surgery (OGS) 65.10.2.2 Single-Stage Release with DO 65.10.2.3 Single-Stage Release with Genioplasty 65.11 Guidelines for sequencing of release and deformity correction 65.11.1 In Ankylosed Patients: To Decide Regarding Distraction Pre-/Post-/Simultaneously with Release (Table 65.5) 65.11.2 In Released Patients: To Decide Regarding Type of DO 65.12 Unfavorable Results in TMJ Ankylosis Surgery (Table 65.6) 65.13 Conclusion 65.14 Case Scenarios Case 1 (Fig. 65.16a–h) Case 2 (Fig. 65.17a–f) References Part XVIII: Orthognathic Surgery 66: Diagnosis and Planning in Orthognathic Surgery 66.1 Introduction 66.2 Systematic Aesthetic Facial Evaluation 66.2.1 Frontal View 66.2.2 Profile View 66.3 Clinical Evaluation 66.4 Special Investigations 66.5 Diagnosis and Problem List 66.6 Treatment Objectives 66.7 Treatment Plan 66.8 Treatment 66.9 Conclusion 66.10 Case Scenarios References 67: Surgery-First Orthognathic Approach 67.1 Introduction 67.2 Background 67.3 Surgery-First Orthognathic Approach (SFOA) 67.4 Regional Accelerated Phenomena (RAP) 67.5 Indications 67.6 Treatment Planning Considerations 67.6.1 General Guidelines 67.6.2 Specific Guidelines [15] 67.7 Treatment Protocol (Table 67.2) 67.8 Protocol Variations 67.8.1 Timing of Bonding 67.8.2 Initial Arch Wires 67.9 Procedural Guidelines for Model Mounting and Model Set-Up in SFOA (Fig. 67.3) 67.10 Surgical Procedures (Fig. 67.4) 67.11 Advantages and Disadvantages of SFOA (Table 67.3) 67.12 The Future of “Surgery-First” Approach 67.13 Conclusion 67.14 Case Scenarios Case Scenario 1 (Fig. 67.6) Case Scenario 2 (Fig. 67.7) References 68: Orthognathic Surgery for Mandible 68.1 Introduction 68.2 Surgical Anatomy of the Mandible (Fig. 68.1a, b) 68.3 Classification of Deformities of the Mandible (Table 68.1) 68.3.1 Mandibular Excess 68.3.2 Mandibular Deficiency 68.3.3 Deformities of Chin 68.3.4 Facial Asymmetry 68.4 Ramus Osteotomies 68.4.1 Extraoral Vertical Ramus Osteotomy 68.4.2 Sagittal Split Osteotomy 68.4.3 Vertical Ramus Osteotomy: Intraoral Approach 68.5 Body Osteotomy of Mandible 68.6 Symphyseal Osteotomy 68.7 Lower Anterior Subapical Osteotomy 68.8 Total Subapical Osteotomy Mandible 68.9 Posterior Subapical Osteotomy Mandible (Fig. 68.28) 68.10 Genioplasty 68.11 Extended Genioplasty/Mandibular Basal Osteotomy 68.12 Distraction Osteogenesis 68.13 Conclusion 68.14 Case Scenarios Case 1 (Fig. 68.38a, b, c) Case 2 (Fig. 68.19a, b, c) References 69: Orthognathic Surgery for the Maxilla-LeFort I and Anterior Maxillary Osteotomy 69.1 History of Maxillary Osteotomies 69.2 Surgical Anatomy 69.3 The Anterior Segmental Maxillary Osteotomy 69.3.1 Technique (Video 69.1) 69.3.2 Exposure 69.3.3 Extractions and Horizontal Osteotomies 69.3.4 Final Osteotomy and Down-Fracture of the Premaxilla 69.3.5 Midpalatal Osteotomy 69.3.6 Fixation 69.3.7 Closure 69.4 Le Fort I Osteotomy 69.4.1 Operative Technique (Video 69.2) 69.4.2 External Reference Marker 69.4.3 Surgical Exposure 69.4.4 Bony Osteotomies 69.4.4.1 Lateral Osteotomies 69.4.4.2 Pterygoid Plate Separation 69.4.4.3 Lateral Nasal Wall and Septal Osteotomies 69.4.5 Down-Fracture and Mobilization 69.4.6 Removal of Posterior Interferences 69.4.7 Placement of Surgical Guide 69.4.8 Removal of Anterior Interferences 69.4.9 Fixation, Grafts, and Final Measurements 69.4.10 Checks to Be Made Before Plate Fixation of the Maxilla 69.4.11 Closure 69.4.11.1 Nasal Cinch Suture (Alar-Base Suture) [62] 69.4.11.2 V-Y Closure [63] 69.4.11.3 Vestibular Closure 69.5 Quadrilateral (Quadrangular) Osteotomy 69.6 Surgically Assisted Rapid Palatal Expansion (SARPE) 69.7 Sequence of Bimaxillary Surgery (Fig. 69.31a–m) 69.8 Soft Tissue Changes with Le Fort I Osteotomy 69.9 Specific Considerations 69.9.1 Adjustment to the Anterior Nasal Spine and Piriform Aperture 69.9.2 Effect of Changing the Inclination (Slope) of the Osteotomy Cut 69.9.3 Impacted Wisdom Teeth 69.9.4 Erupted Wisdom Teeth 69.9.5 Considerations of Pre-operative Difficulties 69.9.6 Considerations of Operative Difficulties 69.9.7 Proper Positioning 69.9.8 Nutritional Support 69.9.9 Complications 69.10 Recent Advances (Refer Figs. 66.21 and 78.51) 69.11 Conclusion 69.12 Case Scenarios Case Scenario 1 (Figs. 69.28, 69.29 and 69.39a–h) Case Scenario 2 (Figs. 69.30, 69.31, 69.32, and 69.40a–i) References Additional Readings 70: Facial Asymmetry 70.1 Introduction 70.2 Classification 70.3 Diagnostic Evaluation 70.3.1 Clinical Evaluation: Frontal, Axial, and Profile 70.3.2 Oral Examination 70.3.3 Photographic Examination 70.3.4 Radiographic Examination 70.3.5 Stereophotogrammetry 70.3.6 Stereolithographic [SLA] Models 70.3.7 Virtual Surgical Planning [VSP]/Computer-Aided Surgical Simulation [CASS] 70.3.8 TMJ Examination 70.3.9 Nuclear Medicine Imaging Modalities (Scintigraphy) 70.4 Clinical Considerations 70.4.1 Occlusal and Orthodontic Considerations 70.4.2 Growth and Development of the Craniofacial Skeleton 70.4.3 Role of Functional Orthopedics and Interceptive Orthodontics 70.4.4 Role of TMJ and Considerations for Treatment 70.5 Treatment Planning 70.5.1 Single Jaw Versus Bi-Jaw Surgery 70.5.2 Mandible First Versus Maxilla First Approach 70.5.3 Surgery First Approach (Refer Chap. 67) 70.5.4 Modifications in Surgical Technique for Asymmetry Cases 70.5.5 Soft Tissue Interventions 70.5.6 Distraction Osteogenesis (Also refer Chap. 87) 70.6 Conclusion 70.7 Case Scenarios Case 1: Condylar Hyperplasia with Concomitant Masseteric Hypertrophy (Figs. 70.26a, b, c, 70.27a, b, 70. 28a, b and 70. 29a, b) Case 2: Parry Romberg Syndrome (Figs. 70.30a, b, 70.31a, b, 70.32a, b, c, 70.33a–h and 70.34a–f) References Additional Reading 71: Obstructive Sleep Apnea Syndrome 71.1 Introduction 71.2 Definition 71.3 Etiopathogenesis 71.4 Risk Factors for OSA 71.4.1 Age 71.4.2 Excess Body Weight 71.4.3 Gender 71.4.4 Craniofacial Anatomy 71.4.5 Familial and Genetic Predisposition 71.4.6 Smoking and Alcohol Consumption 71.4.7 Medical Comorbidity 71.5 Clinical Sequelae [6] 71.5.1 Endocrine and Metabolic Effects 71.5.2 Neuropsychological and Social Consequences 71.5.3 Cardiovascular Sequelae 71.6 Epidemiology [7, 8] 71.7 Diagnosis [1] 71.7.1 History and Physical Examination 71.7.2 Polysomnography (PSG) 71.7.3 Imaging Aids 71.7.3.1 Cephalometrics 71.7.3.2 Dynamic Upper Airway Imaging [12] 71.7.3.3 Acoustic Reflex Ion Test 71.8 Clinical Features (Tables 71.2 and 71.3) 71.9 Treatment Modalities 71.9.1 Positive Airway Pressure [13] 71.9.2 Behavioral Strategies [16] 71.9.3 Oral Appliances [17] 71.9.4 Surgical Treatment of Obstructive Sleep Apnea [21] (Table 71.4) 71.10 Adjunctive Therapies 71.10.1 Bariatric Surgery [23] 71.10.2 Medications [23] 71.11 Conclusion 71.12 Case Scenario References Suggested Reading Part XIX: Developmental Deformities of the Oral and Maxillofacial Region 72: Cleft Lip 72.1 Introduction 72.1.1 History of Cleft Lip Repair 72.2 Embryology 72.2.1 Development of the External Face 72.2.2 Embryology of Cleft and its Surgical Implications 72.2.3 Prenatal Diagnosis in Cleft Lip 72.3 Surgical Anatomy 72.3.1 Surface Anatomy 72.3.2 Muscles 72.3.3 Vascular Supply 72.3.4 Nerve Supply 72.3.5 Anatomy of the Unilateral Cleft Lip 72.3.5.1 Nose 72.3.6 Anatomy of the Bilateral Cleft 72.4 Classification and Presentations of Cleft 72.4.1 Classification 72.5 Treatment of Cleft Lip 72.5.1 Timing of Intervention 72.5.2 Basic Treatment Algorithm 72.5.3 Presurgical Nasoalveolar Moulding 72.5.4 Protocols 72.6 Unilateral Cleft Lip Repair 72.6.1 Techniques of Cleft Lip Repair 72.6.1.1 Basic Components of Millard’s Repair (Video 72.1) Labelling of the Flaps 72.6.1.2 Points Marked: The Following Points are Marked in a Classic Millard’s Technique (Fig. 72.18a, b) 72.6.1.3 Modifications to Millard’s Technique External Scar Placement 72.6.2 Step-by-Step Technique of Unilateral Cleft Lip Repair: Author’s Technique (Figs. 72.23, 72.24, 72.25, 72.26, 72.27, 72.28, 72.29, 72.30, 72.31, 72.32, 72.33 and 72.34) 72.7 Bilateral Lip Repair 72.7.1 Techniques of Bilateral Cleft Lip Repair (Video 72.2) 72.7.1.1 Straight Line Repair 72.7.1.2 Millard’s Repair 72.7.1.3 Mulliken’s Repair 72.7.2 Bilateral Lip Repair: Author’s Technique 72.8 Primary Chielorhinoplasty 72.9 Postoperative Wound Care and Outcome Assessment 72.9.1 Outcomes 72.10 Indications for Lip Revision 72.11 Conclusion 72.12 Case Scenarios References 73: Cleft Palate 73.1 Introduction 73.2 Embryology and Anatomy (Figs. 72.1 and 77.1) 73.2.1 Embryology 73.2.2 Muscles 73.2.3 Vascular Supply (Fig. 73.5a and b) 73.2.3.1 Vascular Supply of the Anterior Palate/Premaxilla 73.2.3.2 Vascular Supply of Posterior Palate 73.3 Classification and Presentations of Cleft Palate 73.4 Clinical Evaluation of the Cleft Palate Patient 73.4.1 General Examination 73.4.2 Clinical Assessment of the Cleft 73.4.3 Imaging and Other Investigations 73.5 Preoperative Factors (Box 73.1) 73.6 Principles and Methods of Repair 73.7 Surgical Technique (Figs. 73.12, 73.13, 73.14, 73.15, 73.16, 73.17, 73.18, 73.19, 73.20, 73.21, 73.22, 73.23, 73.24, 73.25, 73.26, 73.27, and 73.28) 73.7.1 Dissection of the Soft Palate 73.7.2 Suturing 73.7.2.1 Uvula 73.8 Complications: (Box 73.3) 73.8.1 Early Complications 73.8.2 Long-Term Complications 73.9 Long-Term Results 73.9.1 Secondary Repair and Revision 73.10 Recent Techniques 73.11 Case Scenario References 74: Alveolar Bone Grafting 74.1 Introduction 74.2 Normal Anatomy of Alveolus 74.2.1 Development of Alveolar Process (Figs. 72.1, 73.1, and 77.1) 74.2.2 Structure of Alveolar Process 74.2.3 Functions of Alveolar Bone 74.3 Alveolar Anatomy in Cleft Patients 74.3.1 Abnormalities of the Alveolus and Dentition 74.3.2 Abnormalities of the Lip-nasal Complex 74.4 Role of the Orthodontist in Patients with Alveolar Cleft (Box 74.3) 74.4.1 Infancy 74.4.2 Primary Dentition 74.4.3 Mixed Dentition 74.4.4 Permanent Dentition 74.5 Alveolar Bone Grafting Procedure 74.5.1 History [1] 74.5.2 Classification 74.5.3 Materials Used in Alveolar Bone Grafting 74.5.3.1 Bone Grafts 74.5.3.2 Autogenous Materials 74.5.3.3 Alloplastic Materials 74.5.3.4 Allogenic Materials 74.5.4 Technique for Alveolar Bone Grafting 74.5.5 Postoperative Assessment of Alveolar Bone Grafting 74.6 Complications of Alveolar Bone Grafting 74.6.1 Donor Site Complications 74.6.2 Recipient Site Complications 74.7 Conclusion 74.8 Case Scenarios Case 1 (Fig. 74.18a–f) Case 2 (Fig. 74.19a–j) Case Presentation References 75: Cleft Maxillary Hypoplasia 75.1 Introduction 75.2 Features of Cleft Maxillary Hypoplasia 75.3 Objectives of Treatment (Box 75.4) 75.4 Sequencing Treatment in CMH (Box 75.5) 75.5 Orthodontics in Cleft Lip and Palate Patients 75.6 Considerations Before Surgery 75.6.1 Timing of Surgery 75.6.2 Status of Alveolar Bone Grafting and Oronasal Fistulae 75.6.3 Velopharyngeal Insufficiency (VPI) 75.6.4 Degree of Maxillary Hypoplasia 75.7 Treatment Plans 75.7.1 Pearls for Treatment Planning 75.7.2 Age Group of 6–11 Years (Fig. 75.1) 75.7.3 Age 12–16 Years (Fig. 75.3) 75.7.4 Age 17 Years and Above (Fig. 75.7) 75.8 LeFort I Procedure for Cleft Maxillary Hypoplasia 75.8.1 Preoperative Investigations 75.8.2 Preoperative Preparation 75.8.3 Intubation 75.8.4 General Anesthesia 75.8.5 Cleft LeFort I Osteotomy (Video 75.2) 75.8.6 Additional Steps Performed on a Case-to-Case Basis 75.8.6.1 Deciding the Level of Midface Advancement (Fig. 75.15a–f) 75.8.6.2 Preserving the Descending Palatine Artery 75.8.6.3 Grafting of the Osteotomy Site 75.9 Clinical Morbidity and Psychological Response 75.10 Stability of Results 75.10.1 Soft Tissue Envelope 75.10.2 Magnitude of Planned Surgical Movement 75.10.3 Status of Alveolar Bone Grafting 75.10.4 Intraoperative Factors 75.10.5 Timing of Surgery 75.10.6 Degree of Relapse 75.10.7 Clinical Suggestions to Avoid Relapse 75.11 Complications 75.12 Conclusion References 76: Cleft Rhinoplasty 76.1 Introduction 76.2 Pathologic Anatomy 76.2.1 Unilateral Cleft Nasal Deformity 76.2.2 Bilateral Cleft Nasal Deformity 76.3 Surgical Timing 76.3.1 Primary Rhinoplasty 76.3.2 Intermediate Rhinoplasty 76.3.3 Secondary or Definitive Rhinoplasty 76.4 Preoperative Evaluation 76.4.1 History 76.4.2 Physical Examination 76.4.3 Photographic Documentation 76.4.3.1 Two-Dimensional Photographs 76.4.3.2 Three-Dimensional Imaging 76.4.4 Radiographic Assessment 76.4.4.1 Cephalometric Analysis 76.4.4.2 Computed Tomography (CT)/Cone Beam Computed Tomography (CBCT) 76.4.5 Facial Casts 76.4.6 Video Recording 76.4.7 Functional Assessment 76.5 Surgical Correction 76.5.1 Surgical Approaches 76.6 Primary Rhinoplasty 76.6.1 Unilateral Cleft Nasal Deformity 76.6.2 Bilateral Cleft Nasal Deformity 76.7 Intermediate Rhinoplasty 76.7.1 Unilateral Cleft Nasal Deformity 76.7.2 Bilateral Cleft Nasal Deformity 76.8 Secondary or Definitive Rhinoplasty (Video 76.1) 76.8.1 Nasal Base 76.8.2 Septum 76.8.3 Middle Third of the Nose 76.8.4 Nasal Tip or LLCs 76.8.5 Alar Rim (Lateral Crus of LLC) 76.8.6 Nasal Dorsum and Nasal Osteotomies 76.8.7 Piriform Rim and Pre-maxilla Augmentation 76.8.8 Nasal Alae 76.9 Use of Grafts in Definitive Rhinoplasty 76.9.1 Contouring Grafts 76.9.2 Reconstructive Grafts 76.10 Treatment Strategy for Unilateral and Bilateral Cleft Nasal Deformities 76.10.1 Unilateral Cleft Nasal Deformity 76.10.2 Bilateral Cleft Nasal Deformity 76.11 Outcomes in Cleft Rhinoplasty 76.12 Further Revisions in Cleft Rhinoplasty 76.13 Complications 76.14 Conclusion 76.15 Case Scenarios References Part XX: Craniofacial Anomalies 77: Rare Facial Clefts 77.1 Introduction 77.2 Incidence 77.3 Embryology 77.3.1 The Initiation of Craniofacial Development 77.3.1.1 Establishment and Fusion of the Facial Prominences (Figs. 77.1 and 72.3) 77.3.1.2 The Frontonasal Prominence 77.3.1.3 The Lateral Nasal Prominences 77.3.1.4 The Maxillary Prominences 77.3.1.5 The Mandibular Prominences 77.4 Etiology and Pathogenesis 77.5 Classification 77.5.1 Tessier Classification 77.5.1.1 Number Zero 77.5.1.2 Number 1 Cleft Soft Tissue Characteristics: Skeletal Involvement: 77.5.1.3 Number 2 Cleft 77.5.1.4 Number 3 Cleft Soft Tissue Characteristics [35, 46] 77.5.1.5 Number 4 Cleft 77.5.1.6 Number 5 Cleft 77.5.1.7 Number 6 Cleft 77.5.1.8 Number 7 Cleft 77.5.1.9 Number 8 Cleft (Fig. 77.2) 77.5.1.10 Number 9 Cleft 77.5.1.11 Number 10 Cleft 77.5.1.12 Number 11 Cleft (Fig. 77.2) 77.5.1.13 Number 12 Cleft 77.5.1.14 Number 13 Cleft 77.5.1.15 Number 14 Cleft 77.5.1.16 Number 30 Cleft 77.6 Treatment of Craniofacial Clefts 77.6.1 Tessier No. 0–14 Cleft 77.6.2 The Orbital Zone and Skull Bone Defect 77.6.2.1 Resection of Encephalocele 77.6.3 Orbital Hypertelorism 77.6.3.1 En Bloc Osteotomies (Fig. 77.25a–d) Pre-op Evaluation Facial Bipartition 77.6.3.2 Box Osteotomy (Fig. 77.28a–d) 77.6.3.3 Spectacle Osteotomy (Fig. 77.29a–e) 77.6.3.4 Soft Tissue Management Nasal Clefts Inventory of Nasal Components Staged Reconstruction Replace Like with Like Cartilage Nasal Lining Skin Reestablish Nasal/Facial Aesthetics 77.6.4 Tessier No. 4 (Fig. 77.37a, b) 77.6.4.1 Managing the Lid Segment 77.6.5 Tessier No. 5–9 Cleft (Fig. 77.38a, b) 77.6.6 Tessier No. 7 77.6.6.1 Bone Grafts 77.7 Conclusion References 78: Hemifacial Microsomia (HFM) and Treacher Collins Syndrome 78.1 Introduction 78.1.1 Epidemiology and Etiopathogenesis 78.1.2 Classification Systems 78.1.2.1 SAT Classification Type 1 Type 2A Type 2B Type 3 78.1.3 Clinical Features 78.1.3.1 Skeletal Defects Cranio-orbital Maxillomandibular 78.1.3.2 Soft Tissue Defect Skin Tags Macrostomia External Ear Deformities Muscle Deficit Cranial Nerve Abnormalities Soft Palate Function 78.1.4 Radiological Assessment 78.1.5 Differential Diagnosis of Hemifacial Microsomia 78.1.6 Principles of Management of Craniofacial/Hemifacial Microsomia 78.1.6.1 Neonates and Infants 78.1.6.2 Airway 78.1.6.3 Management of Associated Orofacial Clefting 78.1.6.4 Intermediate Surgical and Orthodontic Management 78.1.6.5 Correction of Maxillomandibular Complex Functional Appliance Therapy Ear Reconstruction Delayed Management in Adults Orthodontics for Definitive Skeletal Surgery Type 1 and 2A Type 2B Type 3 Management of the Maxillomandibular Complex Type 1 Type 2A Types 2B and 3 78.1.7 Controversies in Surgical Management of HFM 78.1.8 Long-Term Results 78.1.9 Recent Advances 78.2 Treacher Collins Syndrome 78.2.1 Introduction 78.2.2 Clinical Features and Presentation 78.2.3 Imaging for TCS 78.2.4 Proposed Classification 78.2.4.1 Methods 78.2.4.2 Classification of Temporomandibular Joint and Mandibular Malformation 78.2.5 Differential Diagnosis 78.2.6 Treatment 78.2.6.1 Multidisciplinary Management: Team Members Necessary from Birth to Adult Stage 78.2.6.2 Airway Management 78.2.6.3 Feeding Problem 78.2.6.4 Brain and Psychological Development in TCS 78.2.6.5 Management of Cleft Palate 78.2.6.6 Ophthalmological, Auricular and Hearing Issues Ophthalmological Issues Hearing Issues Microtia Correction 78.2.6.7 Nasal Issues 78.2.6.8 Dentoalveolar Issues and Orthodontic Alignment 78.2.6.9 Management of the Adult TCS Patient Clinical and Cephalometric Features 78.2.6.10 Surgical Management of the Orbito-zygomatic Region Types 3 and 4 78.3 Conclusion 78.4 Case Scenarios Case 1: Treacher Collins Syndrome (Fig. 78.43a–f) Case 2: Hemifacial Microsomia (Figs. 78.45a–e, 78.46a–c, 78.47a, b, 78.48a–c, 78.49a–c, 78.50a, b, 78.51, 78.52a–d, 78.53a, b) References 79: Modern Management of Craniosynostosis 79.1 Introduction 79.1.1 Definition 79.1.2 Aetiology 79.1.2.1 Primary Craniosynostosis 79.1.2.2 Secondary Craniosynostosis 79.1.3 Epidemiology 79.1.4 Classification 79.2 Management 79.2.1 Prenatal Diagnosis 79.2.2 Perinatal Care (Table 7.2) 79.2.3 Care in Infancy 79.2.4 Management in Early Childhood (3–8 Years) 79.2.5 Management in Middle Childhood (8–12 Years) 79.2.6 Management in Adolescence and after the Completion of Growth References Part XXI: Malignant Pathologies of the Oral and Maxillofacial Region 80: Premalignant Lesions and Conditions of the Oral Cavity 80.1 Premalignant Lesions 80.2 Aetiogenesis 80.3 Leukoplakia 80.4 Proliferative Verrucous Leukoplakia 80.5 Erythroplakia 80.6 Submucous Fibrosis 80.7 Oral Lichen Planus 80.8 Chronic Hyperplastic Candidosis 80.9 Premalignant Conditions 80.10 Tissue Biopsy 80.11 Conclusion References 81: Oral Squamous Cell Carcinoma: Diagnosis and Treatment Planning 81.1 Background and Incidence 81.2 Introduction 81.3 Etiology of Oral Carcinoma 81.4 Precancerous Situations of Oral Cavity 81.4.1 Precancerous Conditions 81.4.2 Oral Submucous Fibrosis (OSMF) 81.4.2.1 Molecular Pathogenesis of OSMF 81.4.3 Oral Lichen Planus 81.4.4 Precancerous Lesions 81.5 Diagnosis of Oral Squamous Cell Carcinoma (OSCC) 81.5.1 Clinical Features of Oral Carcinoma 81.6 Imaging in OSCC Diagnosis 81.7 Tissue Sampling 81.7.1 Histopathology 81.7.2 Depth of Invasion/Tumor Thickness 81.7.3 Pattern of Invasion 81.7.4 Perineural Invasion (PNI) 81.7.5 Lymphovascular Invasion (LVI) 81.7.6 Bone Invasion 81.8 Neck Assessment in OSCC 81.9 Distant Metastasis 81.10 TNM Staging System 81.10.1 AJCC Eighth Edition Clinical Staging System 81.11 Treatment Planning for the Management of Head and Neck Malignancy 81.11.1 Introduction 81.11.2 MAGIC: Making Good Decisions in Collaboration 81.11.3 The Start of Treatment Planning 81.11.4 The Second Meeting 81.11.5 Staging Scans 81.11.6 Localization of Primary Tumor 81.11.7 Evaluation of the Neck 81.11.8 The Role of Sentinel Node Biopsy 81.11.9 The Multidisciplinary Team 81.11.10 Planning Reconstruction 81.11.11 Conclusion References 82: Principles of Surgical Management of Oral Cancer 82.1 Introduction 82.2 Initial Evaluation and Staging 82.3 Category for Oral Cavity Cancer, Eighth Edition Staging Manual 82.4 Principles of Surgical Management 82.5 Treatment Decision Algorithm [14] 82.6 Indications for Adjuvant RT and Adjuvant CT + RT 82.7 Principles of Ablative Surgery 82.8 Sub-Site-Wise Surgical Management 82.8.1 Tongue and Floor of Mouth 82.8.1.1 Surgery 82.8.2 Buccal Mucosa 82.8.2.1 T1/T2 Lesions 82.8.3 Gingivobuccal Sulcus 82.8.4 Retromolar Trigone Carcinoma 82.8.5 Hard Palate 82.8.5.1 Brown’s Classification System for Maxillary Defects [25] (Fig. 82.35) 82.8.6 Lip Carcinoma 82.8.6.1 Management of the Neck in Oral Cavity Introduction 82.9 Evaluation and Diagnosis 82.10 Management 82.11 Complications of Neck Dissection References 83: Sarcoma of the Maxillofacial/Head and Neck Region 83.1 Introduction 83.2 Classification 83.3 Staging 83.4 Natural History and Prognostic Factors 83.5 Principles of Treatment 83.6 Principles of Surgery 83.6.1 Hard Tissue Sarcomas 83.6.2 Soft Tissue Sarcomas 83.7 Clinical Assessment 83.8 Investigations 83.9 Osteosarcoma 83.10 Malignant Fibrous Histiocytoma 83.11 Liposarcoma 83.12 Rhabdomyosarcoma 83.13 Chondrosarcoma 83.14 Angiosarcoma 83.15 Malignant Schwannoma 83.16 Fibrosarcoma 83.17 Kaposi’s Sarcoma 83.18 Synovial Sarcoma 83.19 Ewing Sarcoma 83.20 Conclusion References 84: Adjunctive Therapy in Oral Cancer 84.1 Introduction 84.2 Basic Principles of Radiotherapy 84.2.1 Biology of Radiation Therapy 84.2.2 Primary Radiotherapy 84.2.3 Indications of Adjuvant Radiotherapy 84.2.4 Effect of Radiation Treatment Delay 84.3 Radiotherapy Techniques 84.3.1 Radiation Dosage and Fractionation Schedule 84.4 Complications of Radiotherapy 84.5 Acute Toxic Effects 84.5.1 Xerostomia 84.5.2 Oral Mucositis 84.6 Chronic Toxic Effects 84.6.1 Osteoradionecrosis of Maxilla and Mandible 84.7 Principles of Chemotherapy 84.7.1 Cytotoxic Chemotherapeutic Agents 84.7.2 Chemoradiation in Oral Cavity Cancers 84.7.3 Induction Chemotherapy Before Surgery 84.7.4 Palliative Chemotherapy in Patients with Oral Cancer 84.8 Conclusions References 85: Access Surgeries and Osteotomies for the Maxillofacial Region 85.1 Bicoronal Scalp Flap 85.1.1 Procedure 85.1.2 Potential Complications and Solutions (Clinical Pearls) 85.2 Midface Access 85.2.1 Potential Complications and Solutions (Clinical Pearls) 85.3 Nasal Swing 85.3.1 Potential Complications and Solutions (Clinical Pearls) 85.4 Per Oral Access 85.5 Soft Tissue Lip Split 85.5.1 Potential Complications and Solutions (Clinical Pearls) 85.6 Visor Flap 85.6.1 Potential Complications and Solutions (Clinical Pearls) 85.7 Transmandibular Approaches 85.7.1 Mandibular Swing 85.7.1.1 Lip Split Paramedian Mandibulotomy 85.7.2 Potential Complications and Solutions (Clinical Pearls) 85.8 Double Mandibular Osteotomy 85.8.1 Potential Complications and Solutions (Clinical Pearls) 85.9 Zygomatic Osteotomy 85.9.1 Potential Complications and Solutions (Clinical Pearls) 85.10 Lateral and Superior Orbitotomies 85.10.1 Potential Complications and Solutions (Clinical Pearls) 85.11 Conclusion 85.12 Algorithms References Additional Readings Lateral Rhinotomy Lip Split Double Mandibular Osteotomies Part XXII: Reconstructive Procedures of the Oral and Maxillofacial Region 86: Soft Tissue Reconstruction of the Maxillofacial Region 86.1 General Considerations 86.1.1 Healing by Secondary Intention 86.1.2 Primary Closure 86.1.3 Grafts 86.1.4 Flaps 86.1.5 Transplantation 86.2 Reconstruction of the Oral Cavity 86.2.1 Reconstruction of the Lips 86.2.2 Reconstruction of the Vermillion 86.2.3 Reconstruction of the Lower Lip 86.2.3.1 Defects Up to one Half of Lower Lip Width 86.2.3.2 Defects Greater Than One Half Lower Lip Width Lip Switch Flaps Karapandzic Flap 86.2.3.3 Subtotal Defects Cheek Advancement Flaps Nasolabial Flaps 86.2.3.4 Reconstruction of the Upper Lip Primary Closure Lip Switch Flaps Perialar Crescentic Advancement Reverse Karapandzic 86.2.3.5 Commissuroplasty 86.2.3.6 Total Lip Defects 86.3 Buccal Mucosa and Cheek 86.4 Floor of Mouth 86.5 Tongue Reconstruction 86.5.1 Primary Closure 86.5.2 Pedicled Flap Reconstruction 86.5.3 Free Flap Reconstruction 86.6 Palatal Soft Tissue Defects 86.7 Facial Reconstruction 86.7.1 Forehead Reconstruction 86.7.2 Eyelid Reconstruction 86.7.2.1 Healing by Secondary Intention 86.7.2.2 Primary Closure and Grafts 86.7.2.3 Local Flaps 86.7.3 Ear Reconstruction (Also refer Chap. 35) 86.7.4 Nasal Reconstruction 86.7.5 Reconstruction of the Extraoral Cheek References 87: Distraction Osteogenesis of the Maxillofacial Region 87.1 Introduction 87.2 History of DO 87.3 Biology of Transport Distraction 87.4 Biology of Bone Transport 87.5 Device Design 87.6 Biomechanical and Vector Consideration in Mandible and Selection of Device 87.7 Classification of Mandibular Defects in TDO 87.8 Indications of TDO 87.9 Presurgical Investigations 87.10 Surgical Procedure 87.11 Biological Consideration While Designing Transport Disc 87.12 Vascular, Clinical, Radiological, and Histological Features of the Regenerated Bone 87.13 Transport Distraction Osteogenesis in Maxilla 87.14 Advantages of TDO 87.15 Complications of Bone Transport 87.15.1 Hypertrophic Regenerate 87.15.2 Drifting of Teeth 87.15.3 Relapse 87.15.4 Straight Regeneration 87.15.5 Midline Consolidation 87.16 Role of Exogenous Growth Factors and Platelet-Rich Plasma (PRP) in TDO 87.17 Conclusion References 88: Hard Tissue Reconstruction of the Maxillofacial Region 88.1 Introduction 88.2 General Principles [1] 88.3 Principles of Reconstruction 88.4 Terminology 88.5 Bone Grafts [2, 3] 88.5.1 Cortical vs Cancellous Grafts 88.5.1.1 Considerations in Usage of rhBMP-2 [4] 88.5.2 Bone Graft Carriers and Fixation Techniques 88.5.3 Costochondral Graft 88.5.3.1 Technique 88.5.3.2 Indications 88.5.4 Autologous Rib Grafts 88.5.5 Iliac Crest 88.5.5.1 Technique 88.5.6 Tibia 88.5.6.1 Tibial Autogenous Cancellous Bone Harvest 88.5.6.2 Technique 88.5.7 Cranial Bone [2] 88.6 Microvascular Free Tissue Transfer 88.6.1 Osteocutaneous Radial Forearm Free Flap (OCRFFF) 88.6.1.1 Indications 88.6.1.2 Technique 88.6.2 Scapula Free Flap [6] 88.6.2.1 Indications 88.6.2.2 Advantages 88.6.2.3 Disadvantages 88.6.2.4 Technique 88.6.3 Fibula Free Flap [8, 9] 88.6.3.1 Anatomy 88.6.3.2 Preoperative Assessment 88.6.3.3 Technique 88.6.4 Deep Circumflex Iliac Artery-Based Composite Flap or Vascularized Iliac Crest Flap (DCIA) 88.6.4.1 Indications and Contraindications 88.6.4.2 Vascular Anatomy 88.6.4.3 Technique 88.6.5 Vascularized Rib Graft 88.6.5.1 Lateral Femoral Condyle Free Flap 88.7 Conclusion References Suggested Reading List